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PRACTICAL TREATISE 

' -7 3 / ^ ° n the 

DISEASES OF CHILDREN. 



J. FORSYTH MEIGS, M.D, 

One of the Physicians to the Pennsylvania Hospital; Consulting Physician to the Children's 

Hospital; Fallow of the College of Physicians of Philadelphia; Member of the 

American Philosophical Society, of the Academy of Natural Sciences 

of Philadelphia, of the Pathological Society, of the 

Obstetrical Society, etc. etc. 



WILLIAM PEPPER, M.D., 

One of the Physicians to the Philadelphia Hospital; Lecturer on Morbid Anatomy at the University 
of Pennsylvania; Pathologist to the Pennsylvania Hospital; Fellow of the College of 
Physicians of Philadelphia; Vice-Director of the Biolog. and Micros. Sect, of the 
Academy of Natukal Scunces of Philadelphia; Member of the Patho- 
logical Society, of the Obstetrical Society, etc. etc. 



FOURTH EDITION 

(OF MEIGS ON DISEASES OF CHILDREN"), 

REVISED AND GREATLY ENLARGED. 




PHILADELPHIA: 
LINDSAY & BLAKISTOX. 

18 70. 



\S- 



Entered according to Act of Congress, in the year 1870, by 
LINDSAY & BLAKISTON, 
In the Clerk's Office of the District Court for the Eastern District of Pennsylvani 



CAXTON PRESS OF 
SHERMAN & CO.. PHILADELPHIA. 



733 



t>l 



TO 



GEORGE B. WOOD, M.D., LL.D., 

President of the College of Physicians of Philadelphia; Emeritus Professor of the Theory and Practice 

of Medicine in the University of Pennsylvania; late one of the Physicians to the 

Pennsylvania Hospital, &c. &c, 



AS 
A TRIBUTE OF RESPECT FOR HIS HIGH PROFESSIONAL ATTAINMENTS 

AND 

eminent private Virtues, 

AND AS 
A MARK OF GRATITUDE FOR HIS VALUABLE INSTRUCTIONS, 

BY 
THE AUTHORS, 



J. Forsyth Meigs, 
William Pepper. 



PREFACE 

TO THE FOURTH EDITION. 



It has been some years since the third edition of Meigs on the 
Diseases of Children has been exhausted ; and the frequent inquiries 
which have been made for the work, as well as the increasing 
interest taken by the profession in the study of the diseases of 
childhood, have led to the belief that the publication of a new edition 
would be received with the same kind favor which has been already 
extended to the three former ones. 

The changes and additions which were necessitated by the great 
advance made during the last decade in our knowledge of a number 
of the diseases of children, as well as by the unavoidable omission 
of any consideration of several important subjects in the previous 
editions of this work, were however of so extensive a character 
that it has been found necessary to associate a collaborator in the 
preparation of the present edition. 

Among the principal of these changes may be mentioned the 
great enlargement of several articles, and especially of those on 
thrush, convulsions, chorea, tracheotomy in croup, and parasitic 
skin diseases. Other articles have been entirely rearranged, or 
even rewritten, as those upon the diseases of the stomach and 
intestines, and upon eczematous affections. In addition to such 
changes, however, there have been no less than seventeen full arti- 
cles added, embracing the following important subjects: diseases 
of the heart, and cyanosis ; diseases of the ccecum and appendix 
vermiformis, and intussusception ; chronic hydrocephalus, tetanus, 
atrophic infantile paralysis, facial paralysis, and progressive paraly- 
sis with apparent hypertrophy of the muscles ; rheumatism, diph- 
theria, mumps, rickets, tuberculosis, and infantile syphilis ; typhoid 



XU PREFACE TO THE FOURTH EDITION. 

fever ; and sclerema. These various additions and changes have 
involved the introduction of more than two hundred pages of new 
matter. Several extensive tables, exhibiting the mortality in this 
city of some of the most common and fatal diseases, in connection 
with the variations of temperature, have been prepared with great 
care from the records of the office of the Board of Health, which 
were opened to examination through the courtesy of Mr. Chambers, 
the Chief Registration Clerk of that office. A copious index has 
also been supplied, which it is trusted will facilitate reference, and 
render the work more practically serviceable. 

Apart from these changes, however, no alteration has been made 
in the general plan of the work. As in the composition of the pre- 
vious editions, the best and most recent foreign and domestic au- 
thorities on the diseases of children have been frequently and 
carefully consulted, and their views fully quoted whenever they 
appeared of practical importance. For the most part, however, 
the opinions expressed in the following pages are those to which 
the authors have been led by their personal observation, and which 
they therefore believe to have been approved by the most searching 
of alb tests, that of practical application. 

It has also been their constant aim, while supplying a sufficient 
amount of information upon questions of etiology, pathology, and 
morbid anatomy, to insure a practical character to the work. With 
this view, an unusual amount of space has been devoted to the dis- 
cussion of the treatment of the different diseases, and in every 
instance the conclusions derived by the authors from their own 
experience have been fully, and, it is hoped, clearly stated. 

In so doing, it has been necessary to consider somewhat at length 
the extremely important questions of the employment of venesec- 
tion, antimony, calomel, and stimulants ; and a fall expression of 
opinion upon each of these points will be found in its appropriate 
place. 

In conclusion, the authors would venture to express the hope 
that their efforts may have been successful in furnishing a work 
which will aid in rendering the study of the diseases of children 
more attractive and clear, their recognition more easy, and which 
may serve as a practical guide in the difficult task of treating these 
disorders. 

Philadelphia, February, 1870. 



TABLE OF CONTENTS. 



PAGE 

Preface, 7 

Introductory Essay, . , .17 



CLASS I. 

DISEASES OF THE RESPIRATORY ORGANS. 

CHAPTER I. 

DISEASES OF THE UPPER AIR-PASSAGES. 

SECTION I. 

Article I. Coryza, , .. 52 

SECTION II. 

diseases of the larynx. 

General Remarks, 61 

Article I. Simple laryngitis without spasm, . . ... 62 

" II. Spasmodic simple laryngitis, ....... 68 

" III. Pseudo-membranous laryngitis, ...... .. . 84 

CHAPTER II. 

diseases of the lungs and pleura. 

General Remarks, . 130 

Article I. Atelectasis pulmonum, . . . . . . . . 131 

" II. Pneumonia, 153 

" III. Bronchitis, 188 

" IV. Pleurisy, 211 

" Y. Hooping-cough, 230 



CLASS II. 

DISEASES OF THE CIRCULATORY ORGANS. 

Article I. Cyanosis, 252 

" II. Diseases of the heart, 260 



XIV TABLE OF CONTENTS. 

CLASS III. 

DISEASES OF THE DIGESTIVE ORGANS. 

CHAPTER I. 

DISEASES OF THE MOUTH AND THROAT. 

Article I. Simple or erythematous stomatitis, 

" II. Aphthae, 

" III. Ulcerative or ulcero-membranous stomatitis, 
" IV. Gangrene of the mouth, .... 

" V. Thrush, 

" VI. Simple or erythematous pharyngitis, . 



PAGE 

268 
269 
272 
276 
287 
310 



CHAPTER II. 

i 

diseases op the stomach and intestines. 

General Remarks, 315 

SECTION I. 

FUNCTIONAL DISEASES OR MILD CATARRH OF THE STOMACH AND 

INTESTINES. 

Article I. Indigestion, 316 

" II. Simple diarrhoea, 326 

SECTION II. 

DISEASES OF THE STOMACH AND INTESTINES, ATTENDED WITH APPRECIABLE 
ANATOMICAL ALTERATIONS. 

Article I. Gastritis, 336 

" II. Entero-colitis, or inflammatory diarrhoea, .... 342 

" III. Cholera infantum, 378 

" IV. Dysentery, 398 

" V. Diseases of the coecum and appendix cceci, .... 404 

" VI. Intussusception, 419 



CLASS IV. 

DISEASES OF THE NERVOUS SYSTEM. 

General Remarks, 435 

Article I. Tubercular meningitis, 436 

a II. Simple meningitis, 464 

" III. Cerebral congestion, 471 

" IV. Cerebral hemorrhage, 475 

" V. Chronic hydrocephalus, 484 

" VI. General convulsions or eclampsia, 493 

" VII. Laryngismus stridulus, 512 

" VIII. Contraction with rigidity, 529 

" IX. Tetanus, .538 



TABLE OF CONTENT! 



XV 



PAGE 

Article X. Chorea, 546 

" XI. Atrophic infantile paralysis, 569 

" XII. Facial paralysis, 586 

" XIII. Progressive paralysis, with apparent hypertrophy of the 

muscles 587 



CLASS V. 

CONSTITUTIONAL DISEASES. 

Article I. Rheumatism, 591 

" II. Diphtheria, 596 

" III. Mumps, 628 

" IV. Rickets, 632 

" V. Tuberculosis, 643 

" VI. Infantile syphilis, 658 



CLASS VI. 



ERUPTIVE FEVERS. 



Article I. Scarlet fever, or scarlatina, . 
" II. Measles, or rubeola, or morbilli, 
" III. Small-pox, or variola, . 
" IV. Vaccine disease, . 
" V. Varicella, .... 
" VI. Typhoid fever, 



665 
723 

745 

762 

772 
775 



CLASS VII. 

DISEASES OF THE SKIN. 

Introductory Remarks, . 789 

CHAPTER I. 

RASHES. 

Article I. Erythema, 790 

" II. Erysipelas, 795 

" III. Roseola, 803 

" IV. Urticaria, 806 

CHAPTER II. 

vesicles. 

Article I. Eczematous affections, • • £09 

" II. Herpes, 824 

" III. Scabies, ..... 829 



XVI TABLE OF CONTENTS. 

CHAPTER III. 

BULLJE. 

PARE 

Article I. Pemphigus or Pompholyx, 834 

" II. Rupia, 836 

CHAPTER IY. 

PUSTULES. 

Article I. Ecthyma, \ . . 839 

CHAPTER V. 

PAPULES. 

Article I. Strophulus, 842 

" II. Lichen, • .... 843 

" III. Prurigo, .844 

CHAPTER VI. 
Squamse, 846 

CHAPTER VII. 

diseases not classified among the preceding. 

SECTION I. 

parasitic diseases of the skin. 

General Remarks, 848 

Article I. Favus, 851 

" II. Tinea, 858 

" III. Alopecia Areata, 864 

SECTION II. 
Article I. Sclerema, 865 



CLASS VIII. 

WORMS IN THE ALIMENTARY CANAL. 

General Remarks, . 870 

Article I. Ascaris lumbricoides, ........ 873 

" II. Ascaris vermicularis, 885 



PRACTICAL TREATISE 



OX THE 



DISEASES OE CHILDREN. 



INTRODUCTORY ESSAY. 
ON THE CLINICAL EXAMINATION OE CHILDKEN. 

The clinical examination of children, and particularly of young infants, 
cannot be successfully practised upon the same method as that habitually 
made use of in the case of adults. The truth of this statement will be 
readily assented to by all who have had much experience in the treatment 
of the diseases of the two ages, by those who wull reflect for a moment on 
the great differences in the expressions of the various organs in early and 
adult life, and by those who are acquainted with the opinions of distin- 
guished writers upon children's diseases. It is proper and useful, there- 
fore, to preface a practical work on the diseases of children, with a sketch 
or plan of the best method to be pursued in forming a diagnosis of these 
diseases, and with remarks upon the physiological characters which dis- 
tinguish the organization of early life from that of maturity. 

The difficulties that beset the path of the practitioner in his clinical ex- 
amination of children are so great that he who has not been prepared by 
preliminary study to surmount these obstacles, will find it a most uncer- 
tain and dubious task to unravel the history and nature of any case that 
msij be set before him. The helpless silence of the infant, — the wilful 
silence, or the loose and inconsistent answers of the older child, which 
lead astray the mind rather than guide it to true results, — the agitation 
and fright produced b}^ the examination, rendering it impossible at times 
to ascertain the real state of the different functions of the econom}^, — and, 
lastly, the difficulty of obtaining accurate and reliable accounts of the his- 
tory of the case from the attendants, all combine to make the duty of the 
physician most perplexing, and, unless he be gifted with a large share of 
patient and philosophic calmness, most irksome and trying to the temper.. 
So great, indeed, are the difficulties encountered by some practitioners 

2 



18 INTRODUCTORY ESSAY. 

who enter upon this branch of the practice of medicine without proper 
preliminary preparation, that the}- never overcome them; but, to use the 
words of Dr. West, "grow satisfied with their ignorance, and will then, 
with the greatest gravity, assure you that the attempt to understand 
these affections is useless." That it is possible, however, to overcome, 
in great measure, these obstacles, and to arrive at a correct diagnosis in 
nearly all cases, is quite as true as that these obstacles really exist. But, 
in order to do this, the physician must first be aware that difficulties 
exi-t. and must have formed in his mind some plan or method by which 
to surmount or elude them. 

Before proceeding to show what is the best method of examining or ex- 
ploring disease in children, we must state that our remarks apply chiefly to 
infauts and very young subjects ; for, after the age of eight and ten }~ears, 
the physical and intellectual development have progressed to such a point 
as to render the method of diagnosis nearly the same as that employed in 
ad nits. 

The chief causes which render the diagnosis of disease in young chil- 
dren difficult, are the absence of the faculty of speech, and the violent 
agitation generally caused by the examination, which prevents a proper 
appreciation of the state of certain organs and functions. 

It is easy to understand how much our means of diagnosis are restricted 
by the absence of the faculty of speech. How man}- sj'mptoms are there 
in the case of adults with which we become acquainted only through the 
patient's own account of his sensations: and, consequently, of how many 
must we be deprived in children bj- the absence of this account ! It 
might, indeed, at first view, seem impossible to detect the nature of the 
sickness without the assistance of this means, so greatly do we depend 
upon it in our examinations of adults. Nevertheless, we shall find our- 
selves enabled, by an attentive consideration of other resources in the 
child, by a close study of its physiognomical expression, its decubitus, 
the nature of its cry, and by the most rigidly careful physical examina- 
tion, to form our conclusions with almost as great a degree of precision 
as in older patients. 

The other causes of difficulty, — the violent disturbance, both physical 
and moral, of the child, its fright, agitation, and cries, — constitute, when 
they are present in a high degree, much greater embarrassments than the 
want of speech. To overcome these, the physician must use all his skill, 
tact, and patience ; for, unless they can be avoided by art. or overcome 
by soothing and gentle persuasion, he can learn but little that will be of 
essential service to him in making up his opinion. He can neither read 
the countenance of the little patient, nor judge by its attitudes or decu- 
bitus of the state of the various organs, whether internal or external; he 
will be unable to ascertain the rate, force, or regularity of the circulatory 
or respiratory functions; he cannot, to any useful purpose, examine the 
abdomen, to learn whether it be tender on pressure, or whether its con- 
tained organs be in their natural condition as to size and position; and, 
lastly, he will find that the physical exploration of the lungs and heart, 
by auscultation and percussion, yield him at best only imperfect results. 



METHOD OF DIAGNOSIS. 19 

To avoid the difficulties just detailed, it is always useful, if not abso- 
lutely necessary, to conduct certain portions of the examination whilst 
the child is calm and quiet, and certain others whilst it is disturbed and 
agitated. This distinction of the examination into two periods, or stages, 
is one of the utmost importance in a practical point of view, and should 
never be forgotten by the physician during his clinical observation of the 
various symptoms the patient may present. 

By the period of calm is meant a condition of total quiescence, in which 
the child is undisturbed either by internal or external causes of irritation. 
This condition is best found in the state of sleep. If this cannot be ob- 
tained, the one most nearly approaching to it is that which exists during 
the act of nursing, or which follows that act. Suckling is usually fol- 
lowed, even in the sick child, by a condition of drowsiness or by a gentle 
and languid slumber, during which it will allow a careful examination 
upon niauy points without agitation. If possible, therefore, the physician 
should always see the child when asleep, and if the mother or nurse pro- 
pose, on the occasion of his visit, to hurry up stairs to prepare the child, 
or to bring it down into the parlor or lower room, he should ask, as a 
favor, that he may see it asleep. 

If, in spite of having just been nursed, the child be awake and fretting, 
and when, also, it is more advanced in age, we should endeavor, lr^ the 
attraction of toys, by gentle and soothing words and manners, by fondling, 
or by having it carried about the room, to get it quiet. 

Before proceeding to a consideration of the particular means by which 
we are to judge of the state of health or sickness of young subjects, it is 
proper to call attention to the great importance of a careful examination 
of the attendants, in regard to the history of the case, previous to and 
between the medical visits. In the instance of children, their inability 
to describe their own symptoms compels us to depend entirely upon the 
mother or nurse for all detail of the case previous to our first visit, and 
for all accounts of what may have happened between two subsequent 
ones. It is, therefore, extreme^ important that this part of the exami- 
nation should be conducted with every care and caution. Very much 
that is useful may be learned from it, if it be well managed. A great 
deal of skill and art are required in putting the questions, and in sifting 
the evidence thus collected. We should always bear in mind the charac- 
ter of the persons questioned. Much depends upon their education, and 
much more on their natural powers of observation, and manner of relating 
what they may have seen. The degree of credence to be attached to their 
answers must rest upon their probable intelligence. Nurses and mothers 
will often give accounts of their charges which must be received with 
large allowance, and even in some few instances with disbelief. We 
would, however, in this place, most eaimestly caution the young practi- 
tioner of medicine to be very careful not to misbelieve, or even mistrust, 
without well-poised reasons, the account of a sick child given by a mother ; 
for though a foolish, weak woman will often give a false or exaggerated 
statement of the symptoms of her child, an observant and intelligent, and 
sometimes a foolish and weak one, when guided by maternal instinct. 



20 INTRODUCTORY ESSAY. 

will detect variations from the healthful condition of a child, which may 
entirely escape the search of the most acute and rigorous medical observer. 
A mother may perceive a change in the expression of the face, in the 
manner of the muscular movements, in the temper or conduct of her child, 
which shall fail to attract the attention of the practitioner ; or it may be 
that the symptom which has caused the parent to take alarm occurs only 
during the absence of the physician. The medical attendant ought, for 
these reasons, to listen patiently and kindly to whatever the mother or 
nurse may have to say, and if unable to detect immediately what they 
assert the}' have seen, let him not determine at once that there has been 
a mistake, that their anxiety has deceived them ; but let him examine the 
patient yet again, and more carefully, or let him pay another visit to learn 
whether the s3 T mptom or sjmiptoins continue, or have occurred again. 
Our own rule, in a doubtful case, is to listen with religious attention to 
the mother, and unless she be far beneath the average of human intelli- 
gence, our opinion as to the fact of some deviation from the ordinary 
health of the child is considerably influenced by what she tells us. 

The inquiry in regard to the histoiy of the case, previous to the first 
visit of the physician, should bear particularly upon the causes of the 
sickness, its precise moment and mode of attack, and its course and symp- 
toms up to the present time. The most important points to be considered 
in connection with these objects, are the health of the parents, including 
their ordinary health, or their habitual diseases, the causes and periods 
of their death, if they are not living, and the state of health of the child 
at the moment of birth and since. The lrygienic conditions in which the 
patient has been placed ought always to be investigated ; the place of 
habitation ; the kind of house, and whether a large well-ventilated room, 
or a small, narrow, and close one ; the clothing ; the food ; and lastly, 
whether the infant has been suckled, or brought up on artificial diet. 
The state of the health just anterior to the attack ought always to be ex- 
amined into. Has it been good and strong, or feeble and delicate ? If 
delicate, what diseases ? If the approach of any of the eruptive fevers 
be suspected from the character of the symptoms, the question as to 
whether the child has previously had measles or scarlet fever, or has been 
vaccinated or had variola, should always be asked. 

It is next necessary to fix as accurately as possible, the precise period 
of the onset of the sickness. If the question, " When was the child taken 
Bick?" be asked, as it usually is, the answer will be, " Oh, several days 
ago," or, " I don't recollect exactly— I think yesterday, or the day before," 
or some such loose answer. The best way to learn the exact period in a 
recent case, is to go back, day by day, or else to inquire as to some par- 
ticular day. We may ask, was the child quite well day before yesterday ; 
was it well last Sunday? did it play and amuse itself? was it as gay and 
good-tempered as usual yesterday, or the day before, or the day before 
that ? Did it sleep well night before last, or the night before that ? A 
sick child never scarcely sleeps well at night, and very often we may learn 
by close inquiry into this particular, the exact time at which the attack 
began. In this way, by forcing the attendant to tax her memory, and to 



DIAGNOSIS OF ANTECEDENTS. 21 

go minutely over the events of the several clays previous, we shall nearly 
always succeed in fixing very precisely the moment of onset. 

Having determined these points, we should proceed to inquire in regard 
to the course of the disease prior to the first visit. This is to be done 
only by patient and repeated questioning. The questions must be so 
framed as to elicit free and unbiassed answers. They should be general, 
and not leading. Lastly, we are to inquire into the treatment of the case 
up to the present time. 

It is best that all these interrogatories should be made previous to see- 
ing the child, in some other room than the nursery, in order to avoid the 
risk of alarming the child by the presence, during an unnecessary length 
of time, of a stranger. If, however, the child be well acquainted with the 
physician, it matters not where the inquiries are made. 

Having now obtained from the attendants all the information they can 
give in regard to the history and nature of the case, the physician must 
proceed to the personal examination of the patient, in order to determine, 
by his own observation, the exact nature of the sickness, and the treat- 
ment it may require. 

The most important points to be attended to during the clinical exam- 
ination, are the countenance or facies, noting its expression, coloration, 
the presence or absence of furrows and wrinkles from pain, from emacia- 
tion, or from disordered muscular action, the appearances presented by 
the nasal orifices, and especially by the alae nasi, and the characters ex- 
hibited b} T the mouth ;. the sleep ; the cry ; the state of embonpoint or 
emaciation; the condition of the skin as to coloration, temperature, moist- 
ure or dryness, the presence of swellings of any kind, such as those pro- 
duced by dropsy or by affections of the joints, and the existence of erup- 
tions ; the pulse ; impulse of the heart ; the respiration ; the signs furnished 
by the state of the mouth and throat, and J3y the disposition towards and 
power of sucking, or by the manner in which drinks are taken ; and lastly, 
the state of the abdomen. 

The Countenance. — The countenance of a young and healthy infant, 
who is sleeping or perfectly quiet, wears no expression except that of com- 
fort and content. It is composed and still; no movement disturbs its in- 
nocent tranquillity, unless, perhaps, some gentle smile light it up from 
time to time, when we might well believe the happy superstition of the 
fond mother, who will tell us that angels are whispering it. In sickness, 
even when slight, the countenance soon loses this expressionless char- 
acter. In all acute disorders the alteration is very great, such indeed as 
to strike the most careless and inexperienced observer. The features be- 
come contracted, furrows and wrinkles appear about the forehead, the 
nostrils are dilated, or pinched and thin, and the mouth becomes drawn 
and rigid. The extent of the change is generally in proportion to the 
severity of the attack. The part of the face most altered will depend 
very much upon the particular system of organs implicated in the disease. 

Some authors have endeavored to show that different diseases give to 
the physiognomy certain peculiar and characteristic expressions. This 
is true only to a certain extent. Thus, the facies is very different in ab- 



22 INTRODUCTORY ESSAY. 

dominal from that observed in thoracic or cerebral diseases ; but though 
it is generally easy for a practised physician to distinguish by the fades 
alone between a cerebral and thoracic disorder, it is quite impossible for 
him to distinguish between any two cerebral, thoracic, or abdominal 
affections. The particular changes impressed upon the face by different 
diseases cannot, however, be discussed in this place, but must be con- 
sidered in the separate articles upon each disease. Here it can only be 
stated in general terms, that, in diseases of the brain, the upper part of 
the face, the forehead, and the eyes are chiefly affected ; that in diseases 
of the thoracic organs, the middle portion of the face, and especially the 
nostrils ; while in those of the digestive organs, the lower part of the face, 
the mouth and lips, are the parts which undergo the greatest changes in 
their expression. 

Pain may almost always be detected by the expression of the face. It 
gives to the countenance various shades of expression, according to its 
degree of severity, and its permanency or recurrence at intervals. Pain 
in the head is said, by Dr. M. Hall, to produce a contracted brow, pain 
in the belly to occasion an elevation of the upper lip, whilst pain in the 
chest is chiefly denoted by sharpness of the nostrils. We doubt, however, 
whether pain in any particular organ imparts an expression to one part 
of the face rather than to another, for indeed pain in an} T part of the body, 
whether the head, chest, abdomen, or limbs, gives rise to a contraction 
of all the features. Not one part of the face alone, but the forehead, 
mouth, nose, and the whole face, become changed in expression and con- 
tracted, when there is severe pain in any part of the body, so that we 
deem it impossible from the expression alone, to determine where the 
painful sensation ma} T be seated. The countenance merely tells us there 
is pain, but not where it is located. The painful expression will be per- 
manent or occasional, as the pain itself is constant or only paroxj-smal. 

The coloration of the face becomes often an important means of diag- 
nosis. In all the fevers, phlegmasia?, and diseases of general excitement, 
the face will be more or less suffused and red, unless the attack be so 
severe as to occasion a violent shock to the nervous sj'stem, in which 
event the countenance instead of being suffused, is paler than natural. 
In such cases the face becomes of a dead white, all traces of red disap- 
pear, and the skin at the same time has often a slightly shining or var- 
nished appearance. We have not unfrequentry observed this sjmiptom in 
pneumonia and bronchitis, and also in the latter stages of true croup. It 
is a very striking phenomenon, and one which portends great danger. 

In chronic cases of all kinds in which the hematosic and nutritive func- 
tions are enfeebled, the face assumes a pallid and waxen hue, which is 
very characteristic. In the various digestive ailments it becomes icterode 
or sallow, and in affections of the liver more or less yellow. Lastly, in 
certain diseases and malformations of the heart or luno-s, it becomes 
bluish or livid, constituting one of the most important signs of what is 
called morbus cceruleus, blue disease, or c}'anosis. 

In reading the countenance of a sick child, the practitioner should 
always notice the play of the nostrils, since this reveals, to a certain ex- 



SIGNS FROM THE SLEEP. 23 

tent, the state of the lungs. In pneumonia, bronchitis, and pleurisy, the 
movements of the ala? nasi become rapid and energetic, expressing, by 
the degree of their violence and extent, the amount of embarrassment 
under which the respiratory function is laboring. 

The nostrils and nasal passages should always be examined also to 
ascertain the presence of mucous or purulent secretions, or of pseudo- 
membranous deposits, since these fluids or their inspissated products in- 
terfere more or less with the free passage of air through those canals. 

Of the Sleep. — Much useful information as to the state of health of 
infants and children may be obtained from a careful consideration of the 
various pheuomeua connected with their sleep. Of this we are fully con- 
vinced from somewhat long and patient observation. We cannot ascer- 
tain, indeed, the nature of the disease under which the child may be la- 
boring, but we can detect, with very great certainty, the existence of a 
deviation from health. We know of few more certain means of fixing the 
period at which any attack of illness ma}' have begun, than by inquiring 
at what time the child began to have restless or broken sleep, or insomnia. 

A perfectly health}' infant, within the month, who is suckled at an 
abundant and wholesome breast, will usually sleep twenty out of the 
twenty-four hours, waking to nurse every two or three hours during day- 
light, and twice or three times during the night. After the age of two or 
three months, the child is much more wakeful during the day, though it 
will still take a nap of two or three hours in the morning, and a shorter 
one in the afternoon, while it will sleep from early evening until the fol- 
lowing morning, waking but once or twice to suck. Indeed, many per- 
fectly healthy infants, of between three and six or seven months of age, 
sleep without waking from nine or ten o'clock in the evening, until six 
the next morning. After the latter age, the sleep is seldom so unbroken ; 
the child begins to undergo the first considerable trial to its health, den- 
tition, and it is rendered thereby more or less ailing and irritable, and 
consequently restless and troublesome at night. 

Children who have passed through the epoch of dentition, and who are 
perfectly well, usually go to sleep soon after being put to bed, and never 
wake until the following morning. Not only so, but they sleep soundly 
and quietly, without being disturbed by slight sounds, and without toss- 
ing or turning much in their sleep. 

In healthful sleep the whole appearance of the child, its expression of 
countenance, its attitude, and its breathing, all declare a most perfect and 
beautiful ease and tranquillity. Nothing can be more suggestive of the 
comfort and well-being that naturally attend upon health, than the perfect 
composure and graceful postures exhibited by a hearty child during pro- 
found sleep. 

It needs, however, but a slight disturbance of the health of a child to 
break in upon its ordinarily calm and peaceful sleep, and to render this 
restless, fitful, interrupted by startings, cries, or dreams, or insufficient 
The most trifling irritations, as the pressure of a tooth against the gum, 
the presence in the digestive canal of a little imperfectly digested food, 
or of one, two, or three lumbricoides, or the slightest fever from any 



24 INTRODUCTORY ESSAY. 

cause, are sufficient to produce this effect, and hence it is that the charac- 
ter of the sleep will often become to a watchful practitioner the first sign 
of disorder held out by nature. 

The degree of disturbance of this function will vary with the nature 
and severity of the disturbing cause. When slight, the child will con- 
tinue to sleep throughout the ordinary period, but the sleep will be some- 
what uneasy. The countenance will be disturbed. There will be con- 
tractions of the brow, and momentary workings of the features which 
express the perception of some unhealthful sensation. Often the child 
will toss and turn, and change its position more frequently than natural. 
Sometimes it will cry out, and appear distressed by some dream or pain- 
ful sensation. When the cause of disturbance is more serious, the sleep is 
more broken, the child wakes often, and lies awake for a longer or shorter 
time, and it becomes very difficult to lull it to sleep again. Or it has 
painful dreams or nightmare, causing it to scream and struggle in sleep, 
and then to wake in the most violent affright. In severe instances it be- 
comes almost sleepless. We have very often known teething children 
not to sleep more than half as much as in health, and to wear out, by the 
long continuance of this sleeplessness, the patience and even the health 
of their attendants. In some instances they will no longer sleep in the 
bed or crib, and the nurse is obliged to get up and walk with them, or 
soothe them b}^ the movement of a rocking chair or cradle. In other 
cases, the derangement of the health is shown by grinding of the teeth, 
and by the most violent tossing and tumbling about the bed. We have 
frequently seen a child lying with its head where its feet should be, or 
across the bed, and with all the coverings thrown off, in spite of the most 
careful arrangement of the bed-clothes. 

These various disturbances are therefore signs of some alteration in 
the health of the child. They do not lead to an appreciation of the pre- 
cise nature of that alteration, but they are invaluable as affording indica- 
tions of the existence of some morbid condition of the economy. Yery 
often, as above stated, they are the first symptoms of the approach of 
some more or less serious sickness, and as such will often enable us to 
determine, with much precision, the moment of onset of the attack. 

The Cry.— Crying is one of the modes of expression of the child. In- 
deed, this, with the expression of the face, are, according to M. Billard, 
the only means of expression with which nature has endowed the young 
infant. This is, however, scarcely correct, since we may also class amongst 
its means of expression the various spontaneous muscular movements 
indicative of uneasiness, or of pain, or pleasure; the manner in which it 
drinks or sucks, whether eagerly and with appetite, or languidly, or care- 
lessly, or not at all; the enjoyment it receives from pleasant sounds; and 
the evident delight it takes in regarding the light. Nevertheless, the cry 
and the expression of the countenance are the two means on which the 
physician must chiefly rely for early information of the occurrence of 
sickness in the young infant. These are the trusty sentinels of nature. 
By them she first gives notice of the approach of danger, and then meas- 
ures the amount of mischief that may have been done. 



SIGNS FROM THE CRY. 25 

The cry which a child utters during sleep, or even when awake, and 
when nothing has been done to excite or disturb it, is always indicative 
of some uneasiness. If the cry be caused by pain, or by any considerable 
disturbance, it will be accompanied by certain contractions of the features 
and movements of the bod}* and limbs, which will still more strikingly 
show that the pain, or other exciting cause, is of a serious nature. Vio- 
lent and obstinate crying is almost always caused by severe pain, — such 
as the pain of earache. Indeed, obstinate and long-continued crying, 
lasting for hours, is rarely met with except from one of two causes, ear- 
ache or hunger. The cry of earache is often incessant and unappeasable, 
the pain being generally constant, and not paroxysmal, as are most other 
pains. It is to be silenced only by the application of remedies to the 
ear, or by the internal administration of opiates. We have known an 
infant, three months old, to scream with earache for two days and nights, 
with only short lulls of a few hours when brought under the influence of 
large doses of laudanum. As soon as the ear began to discharge, the 
cry ceased. We are constantly called to see infants and young children 
who have been crying most violently for hours, and who are thought to 
have colic, or to have hurt themselves, but who are, in fact, tortured with 
that most violent of all pains, earache. We have met with few instances 
in which such severe and constant crying has depended on other causes; 
for, though children scream violently and obstinately from hunger and 
thirst, the}* may always be quieted by the supply of either want, whilst 
in earache the infant generally refuses the breast, or takes it only for a 
few instants, and then lets go to resume his almost automatic scream. 

To show the difficult}* of sometimes determining the cause of crying, 
we may mention that one of us once attended a nursing baby through 
a severe attack of bronchitis. Just as the child was recovering from the 
attack, it began to cry without any apparent cause. The cry was so con- 
stant, violent, and severe, that, feeling certain from the symptoms that it 
could not be from any dangerous cause, w*e concluded, by the method of 
exclusion, though, to be sure, there was neither tenderness of the ear to 
touch, redness or swelling of the meatus, nor discharge, that it must be 
an earache. Hot applications and opiates applied to the ears did no good, 
and the constant scream set the mother half wild. At length, the grand- 
mother came in and said she thought the child wanted the breast. §ure 
enough, there was the trouble ; the child lay at the breast almost con- 
tinuously for twenty-four hours, and earache, crying and all, vanished. 

In not a few instances we have thus known infants to cry very often 
in the day and night, and sometimes very obstinately, too, from hunger. 
In such cases the child is thought to have colic, and as it is not unfre- 
quently costive, it is dosed with cathartics, carminatives, and opiates ; 
or, it is being brought up partially or wholly upon artificial diet, and as 
a consequence, has some disorder of the bowels, which is thought to re- 
quire other kinds of medicaments for its relief. When the stools are 
natural in appearance, or merely costive, and when the child does not 
labor under flatulence, it is easy, by careful questioning of the mother, 
to discern whether she has milk enough, and by examination of the size 



26 INTRODUCTORY ESSAY. 

and weight of the child, to judge whether growth and nutrition go on in 
their proper ratio ; and if it be found that the mother is a poor nurse, and 
that the development of the child is slow and imperfect, we should at 
once direct an additional supply of nourishment, and the suspension of 
all mere drugs. TVe have often been surprised and delighted to find how 
soon, under the new treatment, the child becomes placid and comfortable, 
how well and how long it sleeps, and at what a rapid rate it develops its 
form and size. So, when the circumstances above referred to coincide 
with a somewhat disordered state of the bowels, we should first choose 
for the child the diet most appropriate to its age and state of health, and 
then, if after inquiry it appears that the whole quantity taken in the 
twenty-four hours is below the proper standard, the amount allowed must 
be augmented. 

The crying occasioned by pain in the head, b} T the pain which accom- 
panies pneumonia or pleurisy, or that which is attendant upon abdominal 
inflammations, is never scarcely constant, though it ruay be violent while 
it lasts. Pain in the head usually causes a sudden and sharp cry or 
shriek, which is over as soon almost as heard, and which has been called 
the hydrencephalic cry. The pain of pneumonia, which, it should be re- 
marked, is not unfrequently absent, or so slight as not to be noticed, 
commonly occasions crying only during coughing, and for a short time 
after, and is accompanied b}~ distortion or grimacing of the features. In 
pleurisy, again, the cry is also heard generally at the moment of cough- 
ing, but it is produced also by the act of moving the child, and by press- 
ure on the affected side. It is commonly much louder, shriller, and in- 
dicative of greater suffering than in pneumonia, and in some cases that 
we have seen, has been very frequent and difficult to appease. 

The cry of intestinal pain may almost always be recognized by the fact 
that it takes place just before or after a stool, that it is accompanied b} T 
wriggling and twisting movements of the trunk, and especially of the 
pelvis, or, in very young infants, by its coincidence with more or less 
flatulence, which is revealed by a tympanitic condition of the abdomen, 
and by frequent regurgitations of gas. 

Children not unfrequently cry much and very obstinately from mere 
fretfulness and general distress or malaise. This kind of crying may be 
recognized by its peculiar tone, which is short, sharp, and irritable. It 
is a fret rather than a scream ; it is occasioned by the least disturbance 
offered to the child, by the attempt to move it, to dress it, to attend to 
any of its wants, even to look at or notice it ; it is moreover possible, 
generally, to still such a cry by soothing treatment, or by the endeavor 
to amuse the little thing with toys. 

Lastly, a child will sometimes attempt to cry, but is unable to utter 
any or only a very faint sound. This depends commonly upon some 
laryngeal impediment, but may be also the result of pure exhaustion ; 
there is not sufficient strength to sound a cry. 

The cry of the young child has been divided by M. Billard into the cry 
proper and the return; and inasmuch as these two portions of the cry are 
differently affected in different diseased conditions, it is important that 



GENERAL APPEARANCE — DEVELOPMENT, ETC. 27 

we should be aware of their existence, and of the effects produced upon 
their manifestations by disease. 

The cry proper is produced during the act of expiration, while the 
return occurs during inspiration. The cry proper is sonorous and pro- 
longed, the return is much shorter and sharper. The return is feeble in 
young infants, and becomes stronger as they advance in age. In different 
states of health, the mode of crying will vary to a considerable extent. 
The cry may exist alone, or in combination with the return; or again the 
return only may be heard, whilst the cry is from some cause suppressed. 
The distinction between the two portions of the cry may always be dis- 
tinctly perceived in a child who is crying violently from any recent cause, 
whether ill-temper, fright, or pain, unless one or other has been suppressed 
by some morbid condition which interferes with the perfect performance 
of the vocal function. After a time, however, when the infant has become 
fatigued with its efforts, the cry proper ceases in part, and we have only 
the return, which is heard from time to time between the sobs. Accord- 
ing to M. Yalleix, it is the return which becomes enfeebled and disappears 
first, whenever one portion only of the cry is heard. Towards the fatal 
termination of all diseases, the return ceases more or less completely, and 
the cry assumes a peculiar moaning or murmuring, which must be familiar 
to all who have been much in the sick-rooms of children. 

With a remark upon the condition of the lachrymal secretion in disease, 
we shall conclude this division of the subject. 

The infant does not begin to secrete tears until towards the third or 
fourth month, and of course this function can furnish no sign previous 
to that time. After that period, however, the suppression of this secretion 
becomes, according to M. Trousseau, a valuable aid to prognosis, as this 
suppression occurs generally in all dangerous acute diseases. The occur- 
rence of this symptom in any acute case should be looked upon, there- 
fore, as one of dangerous augury, while the continuance of the secretion, 
or its reappearance after it has been suppressed, is, on the contrary, a 
highly favorable omen. 

General Appearance of the Child; Development; Embonpoint; 
State of the Skin, etc. — While occupied in hearing the account of the 
sickness given by the mother or attendants, and even while asking ques- 
tions in regard to the present state of the patient, the phj^sician may 
learn a great deal that is useful, by an attentive observation of the general 
appearance of the child as it lies before him. He should study its size 
and development, its state of embonpoint or emaciation, its decubitus 
and gestures, the color, temperature, and dryness or humidity of the skin, 
and the presence of eruptions or swellings of an}^ kind. Having re- 
marked these various matters during the early part of the examination. 
he should proceed to inspect carefully the whole external surface by touch 
and sight, in order to acquire precise and accurate information upon those 
points. 

A child who has been healthy from its birth ought to have attained a 
certain average size and development at a certain age. If it be much 
below the average size, if at three months it look like a new-born child, 



28 INTRODUCTORY ESSAY. 

or at a year old like one of six months, it is very clear that something 
has acted to determine such slow and insufficient growth, and it becomes 
the business of the practitioner to discover what the impeding cause has 
been. Xot only ought a child to have a certain size and stature, but it 
should also be possessed of a certain degree of embonpoint. A perfectly 
healthy young child, one under four years of age, usually presents a 
much greater fulness and rotundity of the trunk and limbs than does the 
adult. Its tissues are firm and solid, its surface of a cool and pleasant 
temperature, its coloration of a clear and exquisite white, finely tempered 
with a faint rosy tint in a warm atmosphere, or slightly marbled with 
light bluish spots in a colder air. Few marks more certainly indicate a 
healthful temper of the constitution than the clear and exquisitely-tinted 
pink color of the palmar and plantar surfaces of the hands and feet of a 
young child. Nothing, indeed, can be more beautiful or perfect in shape 
or contour than the figure of a fine hearty .young child ; nothing more 
pleasing to the eye than its delicate but vivid coloring ; and nothing- 
more expressive of the fulness of health and vitality than its whole 
appearance. 

When, therefore, instead of these marks of a pure and active state of 
the health, we meet with stunted growth, emaciation, soft and flaccid 
tissues, sallow and dingy tint of the cutaneous surface, pallid or bluish 
feet and hands, weak and listless movements, — how eas}' the conclusion 
that some jarring agent is at work to hinder and obstruct the machinery 
of life. 

In acute diseases emaciation takes place rapidly, but the tissues still 
retain some degree of elasticity and firmness. In chronic diseases the 
emaciation is of course slower, but it is more complete, so that, in some 
instances, the frame seems to consist merely of the bones wrapped round 
with a dark and unhealthy skin. The tissues beneath the skin, the cel- 
lular, adipose, and muscular, are in great part absorbed, and the skin 
falls into wrinkles and irregularities on the least movement of the child. 
In some cases of disease, and particularly in those of the abdomen, the 
derm loses almost entirely its elasticity, so that when pinched into a 
fold by the fingers, it retains for some time the form that has been given 
to it. 

The decubitus and gestures of the child ought to be noticed. Healthy 
children are, when awake, almost always in motion. Those who have 
attained the habit of walking are tempted to active exercise by their 
various plays and amusements. Infants, though they sleep much more 
than older children, are also, when awake, constantly moving their limbs; 
they are seldom still. When asleep they rest quietly and comfortably, 
generally upon the side, though often upon the back. How different when 
the child is laboring under disease of any kind ! The disposition to move- 
ment is gone ; the older child insists upon lying on the lap, or in the 
cradle or bed, and the infant is to be soothed of its ciying and fretful- 
ness only by rocking and fondling in the arms. Instead of the free and 
spontaneous movements of health, we now see only the sudden, impa- 
tient, and causeless tossing on the bed or lap, £>r the constant chanoW 



DECUBITUS — MUSCULAR MOVEMENTS. 29 

of position, with fretting or complaining, which constitute the agitation 
of sickness ; or else the slow, languid, and hesitating movements of weak- 
ness or prostration ; or lastly, the stillness and immobility of stupor or 
of coma. 

There is nothing peculiar about the decubitus of pneumonia or bron- 
chitis except when there is severe cbyspnoea, in which case the child, if 
old enough to select its own position, lies high upon the pillows, while 
those who are younger evidently prefer to rest on the lap of the nurse, 
with the trunk and head supported in her arms, and express by crying 
and agitation their discomfort and uneasiness when placed in the recum- 
bent position on the lap, or in the cradle or crib. We have seen several 
young children affected with severe bronchitis or pneumonia, who have 
preferred to any other position that of being held in the nurse's arms, 
with the front of the chest placed against her chest, and the head hang- 
ing over her shoulder. When the d} T spnoea is so severe as to produce, 
by slow degrees, a partial asplryxia and consequent dulness of percep- 
tivity, the child becomes soporous or comatose, and lies usually upon the 
back, as in diseases attended with prostration of strength. 

In pleurisy and peritonitis the decubitus is usually dorsal, and the 
child dislikes to be moved or nursed, often crying violently when touched 
or disturbed. 

In intestinal inflammations the young patient is usually excessively 
restless at first, and very fretful, unless the attack be grave and threat- 
ening, when it often lies still for a time from the prostration of strength 
which attends violent attacks, but becomes restless, turns and twists in 
the bed, cries out, and agitates the lower extremities at each evacuation 
of the bowels. 

In the ear^ period of cerebral inflammation there is generally exces- 
sive restlessness, and great irritability of all the senses and temper, but 
as the case goes on, and passes into the stage of coma, the child becomes 
still and quiet, assuming very often the decubitus called by the French 
" en chien cle fusil ;" that is to say, on the side, with the inferior extremi- 
ties strongly flexed, and the arms drawn close to, or crossed over the 
thorax. This position is especially characteristic of the latter stages of 
tubercular meningitis. 

Extreme restlessness, constant tossing upon the bed, or incessant 
changing from the arms to the bed, or from bed to bed, is a very bad 
sign. We have observed it in several different affections ; especially in 
obstinate pneumonia, in long-continued intestinal disorders, and in the 
secondary inflammations of measles and scarlet fever. 

Amongst the gestures most deserving of attention are the sudden 
starts, attended with cries, which indicate the occurrence of some painful 
sensation, as that of colic, of stitch in the side in pneumonia and pleurisy, 
and sometimes of shooting pain in the head. The frequent carrying of 
the hand to the head, or to the ear, ought not to pass unnoticed, as this 
is often indicative of headache or earache. So also of the constant ap- 
plication of the hand to the mouth, or the introduction of the fingers into 
that cavity, which often occurs when the child is suffering the odontalgic 



30 INTRODUCTORY ESSAY. 

pain of dentition. Nor should the physician ever neglect to observe any 
peculiar and especially any automatic movements of the limbs, and par- 
ticularly of the fingers or toes. Nature often heralds the approach of a 
convulsive seizure by certain peculiar muscular movements. The thumbs 
are drawn into the palms of the hand, and the fingers clasped over them; 
or the toes are strongly bent towards the sole of the foot, or rigidly ex- 
tended ; sometimes the fingers are for an instant convulsively extended 
upon the hand and drawn widely apart from each other; or lastly, the 
muscular movements, instead of being eas} T , steady, and natural, are 
badly co-ordinated ; they are irregular, uncertain, and tremulous. This 
latter character, tremulousness and uncertainty, we have often noticed. 

The occurrence of para^sis will often be unperceived for some length 
of time by an inattentive observer. It is to be discovered by the failure 
of the child to move one limb, whilst the others are more or less agitated, 
or by taking hold of the limb, and comparing the total want of resist- 
ance in it, with a certain stiffness and opposition to movement almost in- 
variably present in the healthful condition. 

The state of the cutaneous surface is alwa} T s important, and ought to 
be careful^ and S3~steinatically examined. The points most requiring to 
be noted are its temperature, dryness or moisture, coloration, and the 
presence of eruptions or swellings. By the temperature, and dryness or 
moisture, taken in connection with the rate of circulation, we must judge 
as to the existence of fever. The inferences to be drawn from the condi- 
tion of the surface in these respects are the same in children as in adults, 
and they need therefore no particular consideration in this place. 

The coloration of the skin, on the contraiy, owing to its great suscepti- 
bility to change in certain affections, becomes, in the diseases of early 
life, of very considerable importance in diagnosis, and deserves therefore 
some special remarks. 

The plrysician should be aware, in the first place, that the color of a 
new-born infant is some shade of red, varying from a deep brick-red tint, 
to one of a much lighter hue. The red appearance fades away usually in 
about four or five days, and leaves the surface of a yellowish-white, or in 
some instances of a decidedly ^yellow color. The yellow color is some- 
times so marked as to impose very readily upon an inexperienced person 
the idea that it must depend on an affection of the liver, or, in other 
words, that it constitutes a true jaundice. In a very large majority of 
cases, however, the conjunctiva retains its natural white tint, the digestive 
functions go on with perfect regularity, there is no fever, and indeed no 
marks of decided disorder of the health, so that the icterode hue cannot 
depend, under these circumstances, on any serious lesion of the liver or 
its appendages, and it is manifestly wrong to regard the case as one of 
disease, or as requiring any treatment. 

Besides the yellow color just described, the cutaneous surface in chil- 
dren, and particularly in those under three or four years of age, very 
often exhibits different shades of a bluish color, which need some attention. 
When the whole skin assumes a decidedly blue tint, the case is one of 
cyanosis or morbus cceruleus, depending on some malformation or disease 



MUSCULAR MOVEMENTS. 31 

of the heart or lungs. In severe cases of this kind, the blue color deepens 
into a purple or even blackish hue. If this appearance last more than a 
very few days, there can be little doubt that it depends on some malfor- 
mation or disease of the heart. 

It is quite common to observe in new-born and very young infants, a 
bluish tint of the hands and feet, and of the parts around the mouth, 
whilst the rest of the body is pale. These appearances depend usually on 
some obstruction to the pulmonary circulation, as that caused by atelec- 
tasis pulmonum, bronchitis, or pneumonia, and they increase, diminish, 
or disappear, according to the course of the causative malady. In older 
children, the blue color of the skin is rarely of any considerable intensity, 
unless the condition has existed from birth, or soon after; but it is not 
at all uncommon to meet with faint, but quite perceptible shades of that 
color, depending on the asphyxiated state which occurs in croup, capil- 
lary bronchitis, pneumonia, and sometimes in laryngismus stridulus. It 
is hardly necessaiy to add, that a very slight blueness of the fingers and 
toes is sometimes observed in the cold stage of intermittents. 

Occasionally we meet with an excessive harshness, aridity, and scurvi- 
ness, with a wrinkled appearance of the skin, especially upon the abdo- 
men and thorax. This s3'inptom, when strongly marked, is usually at- 
tended with enlargement of the superficial veins of that part, and is then 
very striking even to a careless observer. It accompanies very generally 
the abdominal tuberculosis of children, and should not pass unobserved. 
Though generally indicative of tubercular peritonitis, or of tuberculosis 
of the mesenteric glands, it is not always so, since in a case that occurred 
to one of us, and in which it was perfectly well marked, a post-mortem 
examination showed it to have been caused by a chronic peritonitis, re- 
sulting from inflammation and suppuration of the mesenteric glands en- 
tirely independent of tubercular disease. The peritonitis had given rise 
to extensive adhesions amongst the intestines, and the pus had found its 
way by a tortuous sinus between the intestines into the vagina, through 
which it was discharged externally. 

There is one other alteration in the color of the skin which is deserving 
of notice in a practical point of view. It is an excessive pallor, occurring 
sometimes in diseases which obstruct the respiratory function. We have 
been most struck with it in the capillary bronchitis, or suffocative catarrh, 
of j T oung children, and in membranous croup. The whole surface assumes 
a dead white hue, which seems to depend on a total want of blood in the 
cutaneous capillaries. The nose is white, the ears become white and dia- 
phanous, and the only relief the eye meets with in gazing upon what 
seems an almost alabaster countenance, is the still pink or bluish lips, the 
dark eyebrows and eyes, and perhaps a somewhat leaden tint of the cir- 
cumference of the mouth and of the forehead. In strongly-marked cases 
the whole surface exhibits this white or blanched appearance, even the 
fingers and toes. When this condition has lasted for several hours, or a 
day or two, the hands and feet sometimes assume a bluish look, which 
may last until death occurs, or until the attack approaches a favorable 
termination. This condition of the surface, when occurring in cases at- 



32 INTRODUCTORY ESSAY. 

tended with obstruction of the respiratory function, has always appeared 
to us an indication of imminent danger to the patient ; and, indeed, when 
it lasts more than one or two days, it has very generally proved the har- 
binger of death. 

The clinical examination of the cutaneous surface cannot be considered 
complete until it has been made with reference to the presence of erup- 
tions, of swellings from oedema, of inflammation, tumors, and, lastly, of 
diseases of the joints. The inquiry in regard to the presence of erup- 
tions is a very important one, from the fact that children are particularly 
liable to attacks of the exanthematous and other eruptive affections. 
Many attacks of sickness, beginning with violent fever and other serious 
symptoms, which would otherwise remain entirely obscure or unex- 
plained, until a much later period from the onset, may be accounted for 
at an early period by a minute examination of the .skin. So, in the latter 
stages of long and debilitating maladies, in the disorders which follow 
scarlatina, and in cardiac and hepatic diseases, a proper inspection of 
the surface will reveal cedematous effusions that might, if this search were 
neglected or carelessly prosecuted, remain undiscovered. The same re- 
marks will apply to inflammations of the articular cavities, to the swell- 
ing of the joints produced by rheumatism, and to some obscure suppura- 
tive inflammations in the limbs of children. A most instructive example 
of the necessity of this close examination, occurred some years ago in the 
practice of one of us. A healthy male infant, five weeks of age, was 
seized suddenly with most violent fever, the reaction being not unlike in 
character that of acute rheumatic fever. The only visible disturbance of 
the health, to explain this violent attack, was a certain amount of diges- 
tive derangement, and for this the patient was treated. After three days 
of most severe illness, with strong tendency to convulsion, and with some 
stiffening of the lower jaw, we were asked to look at the right thigh. It 
was largely swelled, especially in its lower half; it was hard to the touch, 
and the skin over the outside of the limb, just above the knee, had as- 
sumed an inflammatory redness. It was clear that the child had been 
attacked with an acute inflammation of the deep tissues of the thigh, and 
that this was now approaching the surface and becoming visible. Care- 
ful inquiry now brought to light the fact that the baby, all through the 
sickness, had cried severely, as though in sharp pain, whenever it was 
moved, and especially when its napkins were changed. The distress ob- 
served when the napkins were being changed, had been ascribed to some 
smarting from the urine. Had the surface of the child been more care- 
fully examined at an early period, the swelling of the thigh, and the pain 
on motion, might, no doubt, have been detected then, and the intense 
febrile reaction, with the nervous symptoms, which were thought too 
great for simple functional disorder of the digestive functions, would at 
once have been explained. 

It is clear, therefore, that in infants and in children under six or even 
eight years of age, the physician must depend, in great measure, for in- 
formation as to the nature of the case, on his own unassisted explora- 
tions ; and, knowing this, he should leave nothing neglected that may aid 



PULSE. 33 

him to gauge with accuracy the state of health of the individual before 
him. He should cultivate a Jiabit of minute, systematic, and patient in- 
vestigation, since, by accustoming himself to such a method in his daily 
walks, he will assuredly attain, in the end, a tact and sagacity that will 
not often be at fault. 

The Pulse. — The pulse of the child, in order to be judged of to any 
real advantage, must be examined during the state of quiet, and, if pos- 
sible, it should be felt whilst the child is either asleep or dozing. During 
the waking state, a young infant is in such constant motion, that it is 
very difficult to perceive the pulsations of the radial artery, and impossi- 
ble to judge of their force or volume, in consequence of the rising and 
falling of the flexor tendons of the forearm, and because, also, of the 
natural softness and delicacy of the pulse at that age. In older children, 
the moral disturbance occasioned b} r the visit of the physician in most 
instances, and the irritability and nervousness accompanying the sick- 
ness, will either cause the patient to resist the attempt to touch the arm, 
or else produce so great an effect upon the rate and force of the circula- 
tion, as to render very uncertain and unsatisfactory any conclusions to 
be drawn from the examination. If possible, therefore, the circulation 
should be examined during sleep. If this be impracticable, the child 
ought, when still nursing, to be put to the breast, or, when weaned, it 
ought to be quieted 03- soothing treatment, by toys, or by the promise of 
a toy. 

It is essential that we should know what is the average of the healthy 
pulsations of the child, in order to obtain a standard of comparison by 
which to judge of an}' departure from that average in disease. Observ- 
ers have varied not a little in the results at which they have arrived by 
their examinations upon this point. By selecting those, however, which 
appear to have been made with the greatest care, and under the most 
favorable circumstances, we shall, doubtless, obtain an average entirely 
worth}' of confidence. It will be necessary, also, to obtain averages for 
different periods of childhood, since the rate of the circulation varies to 
a very great extent at different ages. We shall, therefore, give the rate of 
the circulation for new-born children (one to ten days old), for the period 
from four months to six years, for that from six to nine years, and for 
those from nine to twelve, and from twelve to fifteen years of age. 

The average rate of the circulation in very young infants, is from one 
hundred and one to one hundred and two in the minute, the former being 
the result obtained by M. Billard in children from one to ten days old, 
as nearly as it can be gained from his statements, and the latter, the one 
obtained by M. Roger, in infants from one to seven days old (De hi 
Temperature chez les Enfants, Paris, 1844). The physician ought, 
however, to be aware of the fact that, though the above is the average 
rate of the circulation at the age mentioned, the pulse may range very 
much above or below that average, without necessarily indicating a mor- 
bid state of the health. Thus, though the average frequency in forty 
children, from one to ten days old, observed by M. Billard. was one 
hundred and one, it was less than eighty in eighteen, whilst in fourteen 

3 



34 INTRODUCTORY ESSAY. 

it was between one hundred and one hundred and twenty-five, and in six 
between one hundred and thirty and one hundred and eighty. All these 
children, he assures us, presented every mark of good health. 

The average frequency of the pulse during the first year maybe stated 
at about one hundred and fifteen, at least such is the result obtained by 
us from an examination of seven observations by M. Roger of children 
from four to nine months old. This result, it will be observed, shows that 
the pulse is not so frequent during the first few days after birth, as it be- 
comes at a somewhat later period, which, moreover, agrees with a previous 
statement to the same effect made by M. Yalleix. This latter author is 
of the opinion that at seven months of age the pulse is much more frequent 
than some days after birth, and that it afterwards falls gradually as the 
child advances in years. 

We are not acquainted with any observations upon the rate of the cir- 
culation during the second } T ear of life, except those of M. Trousseau, 
who, according to M. Bouchut {Manuel Prat, des Mai. des Nouv.-lses, p. 
133, Paris, 1845), gives as the average between one year and twenty-one 
months, one hundred and eighteen. 

M. Becquerel (Traite Theorique et Prat, des Mai. des En f ants, Paris, 
1842), gives us the result of his observations upon thirty children, between 
two and six 3-ears of age, during sleep and in the waking state. During 
sleep the average was seventy-six; in the waking state, it was ninet}'-two. 

Between six and nine years of age, the same observer found the average 
during sleep to be from seventy-three to seventy-four, whilst in the waking 
state it was ninety. Between nine and twelve 3 T ears, the average was, 
during sleep, seventy-two, in the waking state, eighty. Between twelve 
and fifteen years the rate was seventy whilst the children were asleep, and 
seventy-two when awake. Roger gives seventy -seven as the average be- 
tween six and fourteen years. 

One very striking fact attracts our attention in the above statements : 
the much greater difference between the rate of the circulation during 
sleep and during the waking state, in very young children, than in those 
who are somewhat older. Thus, whilst there is a difference of seventeen 
pulsations in the minute, in the rate of the circulation during sleep and 
in those who are awake, between the ages of two and six years, the differ- 
ence under the two conditions mentioned, amounts to only two pulsations 
in the minute in children that have reached the age of between twelve and 
fifteen years. 

The circulation is somewhat more rapid in girls than boys. This dif- 
ference should be borne in mind, but as it amounts to only about five 
beats in the minute, it is insufficient' to be of any very decided value in 
diagnosis or prognosis. 

After these specifications as to the rate of the circulation in children, 
we shall pass on to some general remarks upon the method of the exami- 
nation of the pulse, and upon some other of its important characters. 

M. Bouchut (loc. ciL, p. 129) remarks that in infants at the breast 
" the palpation of the pulse is almost impossible. It may be counted, 
but its force, feebleness, size, and hardness, can scarcely be appreciated; 



EXAMINATION OF THE HEART. 35 

the intermittent character is the only phenomenon upon which no doubt 
need rest ; it is, moreover, the only one of any value." These opinions 
of M. Bouchut. though true in some degree, are much too strongly stated, 
for we are quite sure that it is very easy to detect great differences in the 
force, size, and tension of the pulse of the same child in health and in dis- 
ease, and of different children laboring under different diseased conditions. 
These differences can be detected by careful observation from a very early 
age, and after two months may be readily recognized, when the variation 
from the state of health is at all considerable. 

The intermittence of the pulse above alluded to, should rather be ex- 
pressed by the word irregularity, since the pulse is not properly intermit- 
tent, but merel}* irregular in its rhythm. This is quite a common feature 
in the pulse of children, and, be it noted, is much more frequently met 
with during sleep than in the waking state. M. Becquerel met with irreg- 
ularity of the pulse in twenty-four of one hundred and fifty children exam- 
ined during the waking state, and in fifty-five of one hundred and fifty 
during sleep. It is clear, therefore, that mere irregularity of the circula- 
tion, independentl}' of other S3'inptoms, is not a sign of disease, since it 
was present in one-sixth of those awake, and in a little more than a third 
of those asleep. It should be observed, too, that the greatest irregularity 
exists when the pulse is lowest (in sleep). The chief practical bearing of 
this fact is that we should be careful not to la}^ too much stress upon slow- 
ness and irregularity of the pulse, as signs of tubercular disease of the 
cerebral meninges, unless the}' are observed during the waking state, and 
in connection with other symptoms, particularly with vomiting, constipa- 
tion, and severe headache. 

Another very important characteristic of the circulation of the child, is 
its extreme irritability, which causes its rate to vary to an extraordinary 
degree, even in perfect health. This is the more marked in proportion as 
the child is younger. The slightest disturbance, whether moral or physi- 
cal, will cause the pulse to rise in a young child, from one hundred or one 
hundred and fifteen, to one hundred and twenty, one hundred and thirty, 
or even one hundred and fifty. From this circumstance may be drawn 
the inference also, that the pulse should always be examined, as before 
stated, during sleep, or during profound quiet. 

There is still another reason which makes it necessary to touch the 
pulse during sleep or profound quiet. This is, that when the child is 
agitated, it becomes literally impossible, in consequence of the contrac- 
tions of the flexor tendons of the arm, and of the movements of prona- 
tion and supination, to judge with accuracy the various qualities of the 
arterial action. 

Examination of the Heart. — The examination of the heart by auscul- 
tation and percussion ought, and, to be of essential aid in diagnosis, must 
be performed while the child is still and quiet. It is best made during 
sleep, especially in infants ; when this is impossible, it can be performed 
with great advantage during the state of quiet that follows nursing, or 
during that which may often be procured by soothing management, or by 



36 INTRODUCTORY ESSAY. 

taking advantage of the fondness that infants show for a strong light, the 
view of which will generally suffice to occupy and keep them still. 

The sounds of the heart present the same general characters in the 
child as in the adult. They are, of course, more feeble and more rapid ; 
conditions which make it difficult, in the young infant, to perceive and 
appreciate an}' minute change from the healthful sounds. After the age 
of one and two years, however, when the circulation has become slower 
and more steady, the signs yielded by the physical examination of the 
heart become much more valuable and positive ; so much so, indeed, as 
to yield results almost as important as in the adult. The first sound is 
almost always duller than the second. They succeed each other com- 
monly with perfect regularity, and have the same interval between each, 
in the same child. The cardiac sounds are readily heard by placing the 
ear over the precordial region. The extent of surface over which they 
may be heard, will depend on several conditions : particularly the state 
of quiet or agitation of the child, the presence or absence of fever, the 
state of the lung as to its consistence (constituting it a better or a worse 
conducting medium of sounds), and the condition of the heart itself as to 
health or disease. 

In a healthy child, who is undisturbed by any cause of irritation, and 
particularly in one sleeping, the sounds are distinctly audible over the 
whole precordial region, and under the left clavicle. In many subjects 
they can be heard over the whole front of the thorax, but become of course 
feebler in proportion as we recede from the precordial region. Usually 
the}' are heard quite as distinctly under the right clavicle as over the right 
nipple of that side, in consequence, no doubt, of their transmission in an 
upward direction by the aorta. They are never heard over the posterior 
walls of the chest in children in perfect health, and whose circulation is 
entirely undisturbed. In those who are awake and agitated, and in those 
who have been making severe muscular exertions, the cardiac sounds are 
very loudly audible over the whole front of the thorax, and even through 
to the back of the chest. 

When the lungs are indurated by inflammation, as in pneumonia, they 
transmit with great distinctness, from having become better conducting 
media, the cardiac sounds to the back. This circumstance sometimes be- 
comes a valuable aid in the diagnosis of pneumonia. We have been en- 
abled to satisfy ourselves of the existence of pneumonia in the lower lobe 
of the right lung, in a doubtful case, from the fact that the sounds of the 
heart were much more clear and distinct over the right inferior, than over 
the left inferior dorsal region. 

The precordial region is decidedly less sonorous on percussion than 
the parts of the thorax directly over the lungs. This diminution of sound 
is distinct enough to be evident to any ordinary ear, but it rarely amounts 
to absolute flatness. The region exhibiting this dulness of sound is the 
same in position as in the older person. It occupies the space corre- 
sponding to the cartilages of the fifth, sixth, and seventh ribs, and is situ- 
ated therefore between the left nipple and the left edge of the sternum. 
Its measurements, as given by MM. Rilliet and Barthez, are one and a 



THERMOMETRY OBSERVATIONS IN CHILDREN. 37 

half to three inches in a transverse, by one and a half to two and a half 
in a vertical direction. The region of clulness is described by those ob- 
servers as being represented by a circle or ellipse, the transverse diameter 
of which extends from the nipple to the sternum, or more rarely towards 
the xiphoid cartilage. In children over six years old the nipple some- 
times lies above the middle line of this space. 

Thermometry Observations in Children. — As an indication of the 
intensity and character of the disease in febrile attacks, we have seen that 
the frequency of the pulse is little to be depended on. Dr. Forster (Jour.f. 
Kind., July and August, 1862, in New Syd. Soc. Year Book, 1862, p. 413), 
who has made an extensive series of observations upon this subject, asserts 
that variations in the temperature of the body offer far more certain indi- 
cations. The instrument used was a Reaumur's thermometer, eight and 
a half inches long, in which slight variations are easily appreciable. The 
bulb was placed in the axilla. 

The results given are those of observations upon healthy children, 
during the first few da} T s of life. 

A constant lowering of the temperature of the body takes place after 
birth, which reaches its maximum, 28.97° R., on an average within the 
first two hours after birth. 

Hours after Birth. Average Temp. (R.) Minimum Temp (R ) 

i—2, 28.97 28.2 

2—6, . 29.12 28.1 

6—10, '. . 29.49 28.7 

10—15, 29.53 29.0 

15—20, 29.31 28.8 

20—25, 30.04 29 7 

25—30, 29.9 29.7 

30—36, 30 07 29.7 

36—42, 30.04 29.4 

42—48, 29.86 29.3 

A subsequent elevation always occurs. The average time at which the 
highest temperature was observed, was from thirty to thirty-six hours 
after birth, at which time the average was 30.0*7° R. : maximum 30.4° R., 
minimum 29.7° R. 

This elevation was noticed equally when the infant had and had not 
taken food. 

During the first nine days of life, the temperature was observed as 
follows : 



Days. 


Maximum (R.). 


Minimum (R.). 


Average (R.). 


No. of Observ'ns 


1 -li, . . 


. 30.4 


29.7 


30.01 


22 


14—2, . 


. 30.5 


29.3 


29.93 


16 


2-2J, . . 


. 30 4 


29.3 


29.87 


28 


2§-3, . . 


. 30.3 


29.2 


29.74 


16 


3 — 3£, . 


. 30.3 


29.3 


29.76 


27 


8J— 4, . 


. 30.2 


29.0 


29 68 


17 


4-4J, • • 


. 30.4 


29.2 


29.68 


25 


44-5, . . 


. 30.3 


29.2 


29.72 


18 


o -5|, . . 


. 30.4 


29.2 


29.82 


23 



38 INTRODUCTORY ESSAY, 



Days. 


Maximum (R.). 


Minimum (R.). 


Average (R.). 


No. of Observ'ns. 


5£— 6, . 


. 30.5 


29.3 


29.81 


16 


6 -6£, . 


. 30 6 


29.4 


2983 


23 


6^—7, . 


. 30.3 


29.1 


29.75 


17 


7 — 7-£, 


. 30.4 


29.3 


29.82 


22 


7£— 8, . 


. 30.4 


29.0 


29.72 


11 


8 -8J, . 


. 30.0 


29.4 


29.70 


8 


8A— 9, . 


. 29.9 


29.6 


29.75 


2 



YVe thus see that from the thirtieth to the thirty-sixth hour after birth the 
highest temperature is observed. Then a fall takes place, which reaches 
its maximum at four days after birth (average maximum 29.68° K.). 
Again, between the fifth and eighth days, a new elevation of temperature 
occurs ; but this new elevation is less in degree than that previously noted. 
The average maximum was 29.83° R. Some differences were found in 
the results, according as the children were large and heav} T , or the re- 
verse. Large and well-developed children had a slightly higher tempera- 
ture than those less robust. 

Thus the average temperature in the early part of the day was, in chil- 
dren weighing eight pounds and upwards, 29.84° R.; but, in children 
weighing less than this, the average was 29.65° R. The evening obser- 
vations, again, gave an average for the heavy children of 29.94° ; for the 
others, of 29.77° R. Respecting the temperature at different times of 
the day, observations showed that, from the second to the ninth day, 
there was an average elevation of temperature, from morning to evening, 
amounting to .11° R.: the average morning temperature being 29.7.5° R. ; 
the average evening temperature, 29.86° R. 

This interesting subject has been further examined in regard to older 
children, hy Mr. Finlayson (JProc. of Manchester Med. Soc, in Brit Med. 
Jour., Jan. 16, 1869, p. 59). 

His results are based on two hundred and eighty-one observations on 
eighteen different children, of ages varying from twenty months to ten 
and a half years, and are as follows : 

1. The daily range of temperature is greater in the healthy child than 
that recorded in healthy adults — amounting to 2° F. 

2. There is invariably a fall of temperature in the evening, amounting 
to 1, 2, or 3 degrees. 

3. This fall may take place before sleep begins. 

4. The greatest fall is usually between ? and 9 p.m. (at least under the 
conditions of life in hospital). 

5. The minimum temperature is usually observed at or before 2 a.m. 

6. Between 2 and 4 a.m. the temperature usually begins to rise, such 
rise being independent of food being taken. 

7. The fluctuations between breakfast and tea-time, are usually trifling 
in amount. 

8. There seems to be no very definite relationship between the fre- 
quency of the pulse and respirations, and the amount of temperature; the 
former being subject to many disturbing influences. 

Respiration ; its Rate and General Characters. — The respiration, 



ITS RATE, ETC. 39 

like the pulse, to be examined with any advantage to the explorer, must 
be investigated whilst the child is still and quiet. In the young infant it 
should be done during sleep, as it is only then that we can find the breath- 
ing uninfluenced by disturbing causes other than those connected with 
deranged health. In the older child, the play of whose functions is more 
steady and regular, and less readily jarred by trivial causes, this part of 
the clinical exploration may be made during the waking state ; but, still, 
it must be done whilst the patient is quiet and tranquil, else the results 
obtained will necessarily be less certain and reliable than under the op- 
posite state of things. 

The respiration ought alwa}~s to be counted by the watch, if possible, 
especially by the young practitioner. This is the only mode in which a 
perfectly accurate idea of the frequency of the respiration is to be ob- 
tained. It sometimes happens that a greatly increased rate of the breath- 
ing will pass unnoticed by the physician, from the fact that it continues 
to be regular and without effort. We have known children to breathe 
eighty times in the minute, without presenting any appearance of labor 
or effort in the act; without cough, and without the least wheezing or 
sound to be heard at a short distance from the patient. Under these 
circumstances, the great rapidity of the respiration might very well pass 
unnoticed, especially by inexperienced practitioners ; and, be it remarked, 
this would be particularly apt to happen were the attention of the physi- 
cian addressed to some other part of the economy than the thorax, as the 
seat of the sickness. For instance, in latent pneumonia, when this sim- 
ulates meningitis, or when it is conjoined with gastro-intestinal symptoms, 
the failure to note a greatly increased rate of the breathing, might very 
well occur. In man} T cases of secondary pneumonia, it might also take 
place. In children, who have been long sick with diseases that debilitate 
and impoverish the health, a sudden aggravation of the symptoms depend- 
ent on collapse of the lung, might be misunderstood and falsely explained, 
for the want of this precaution. It is therefore a good and useful rule, 
for the 3 T oung practitioner always to count the respiration, when he has 
to do with a case presenting the least obscurity of diagnosis, since this 
simple habit may guide him to the real seat of disease, which else he 
might mistake. 

The rate of the respiration in children is very different at different 
ages, a circumstance that should abwaj's be recollected in the examina- 
tion of their diseases. The average frequency of the breathing in new- 
born children and during the first week of life, is thirty-nine, according 
to M. Roger. It may rise, however, upon very slight disturbances, to 
fifty, sixty, or even eighty, while it is not at all unusual to find it at 
twenty-five or thirty in perfectly healthy infants during sleep. Between 
the ages of two months and two 3-ears the average is about thirty-five. 
Between two and six years, the average is eighteen during sleep and 
twenty-three during the waking state; from six to twelve years, the 
average during sleep is eighteen, and in the waking state twenty-three: 
from twelve to fifteen years, it is eighteen in the former, and in the latter 
twenty. It will be observed, therefore, that after the age of two years. 



40 INTRODUCTORY ESSAY. 

the rate of the respiration is nearly the same throughout the remainder 
of the period of childhood; it changes so little, indeed, that the same 
average will answer for all practical purposes throughout that period. 

The other characters of the respiration require some attention on the 
part of the practitioner. In the first place, the diaphragm plays a more 
important part in the process in the child than in the adult. In the 
young infant, indeed, the function is carried on almost wholly by the 
action of that muscle, so that the respiration is correctly described by the 
technical term of abdominal. The walls of the chest are almost motion- 
less. On this account the rate and characters of the breathing can be 
best studied in young children, by examining the abdomen, the move- 
ments of which being strong and marked, are much more easily seized 
by the eye than are those of the thorax. 

During perfect quiescence, and especially during sleep, the breathing 
of a young child is soft, regular, though less so than in the adult, and 
perfectly noiseless ; it is necessary to place the ear close to the face or 
chest of the child, and to listen attentively, in order to hear it. In the 
young child, and especially the young infant, the breathing is, in the 
waking state, very different from that of the adult. It is short, irregular, 
uneven, and marked by occasional pauses, followed by a hurry and pre- 
cipitation of the movements. These peculiarities in the respiration of 
the infant appear to depend on the weakness and imperfect action of the 
muscular apparatus at that early age, which causes the various move- 
ments of the bod} T to be hesitating and uncertain, and without that steadi- 
ness and evenness which are characteristic of matured strength. After 
the age of two } T ears, these irregular and tumultuous movements cease, 
and the breathing becomes more regular and even, like that of adults. 

In the inflammatory affections of the lungs, — pneumonia, bronchitis, 
and pleuris}', — the respiration is almost invariably accelerated. In ex- 
tensive pneumonia, and in capillaiT bronchitis, it becomes very rapid, 
rising to eighty or one hundred in the minute. In pleurisj- and simple 
ordinary bronchitis, it seldom becomes so frequent, not exceeding, usu- 
ally, fort}* or fifty. In severe pneumonia, the rhythm of the movement 
sometimes becomes inverted : the pause occurs at the termination of the 
inspiration instead of the expiration. The patient makes first a violent 
and labored expiration, bringing into a kind of convulsive action all the 
expiratoiy muscles of respiration ; instantly after the expiration follows 
a rapid and full inspiration ; then occurs a momentary pause, and again 
the respiratory act begins with the labored expiratory effort. This kind 
of respiration is a very unfavorable symptom, as it is indicative of a most 
dangerous oppression. It is particularly apt to occur in infants, and very 
young children. It has been called expiratoi^y respiration. 

The respiration, though almost invariably accelerated in pulmonary in- 
flammations, sometimes retains its normal rate, or even falls below that 
rate. This occurs, we believe, only under one condition of things : when 
the forces of the constitution have been sapped by previous disease, or 
exhausted by the long continuance of the thoracic inflammation. It is 



SIGNS FROM THE RESPIRATION. 41 

therefore met with in cases of secondary inflammations, and in those of 
the chronic form. 

The respiration is very much increased in frequency as a general rule 
in the form of disease recently described under the title of Atelectasis 
Pulmonum. or collapse of the lungs. When, therefore, a young child 
who has been exposed to the causes of this disease (feebleness at birth, 
exhausting disease, or debilitating hygienic conditions), is suddenly 
seized with hurried respiration, slight cough, paleness or blueness, with 
coldness of the cutaneous surface, and in whom there are but few and 
unimportant physical signs of pulmonary disease, there is very good rea- 
son for supposing that some portion or portions of the lungs have become 
collapsed, or in other words, have ceased to admit air. 

The respiration often lends some assistance in the diagnosis of cere- 
bral affections. In acute meningitis, accompanied by violent febrile re- 
action, it is more frequent than natural, but often irregular. When the 
early stage passes into the stage of coma, the breathing becomes slow and 
irregular. In tubercular meningitis it is seldom increased in frequency 
except for a day or two before death, whilst in the middle period of the 
v disorder, it is either continued at its normal rate, or becomes slower. 
During that period, also, it is almost always extremely irregular, and is 
interrupted by long and mournful sighs, which, to the ear of the experi- 
enced plrysician, who hears in them the almost certain prognostic of ap- 
proaching death, have an inexpressibly touching sound, increased tenfold 
by the consciousness of his utter inability to control the fatal tendency 
of the malady. 

There is a peculiarity of the respiration which occurs in collapse of 
the lung, and also in cases of membranous croup, which ought not to be 
passed b} T unnoticed. It is, that, during the inspiratory effort, the ribs 
move inwards and backwards towards the mesial line of the trunk, instead 
of outwards as in normal respiration ; and at the same time there may 
be recession of the lower part of the sternum, so that a more or less deep 
sulcus is produced around the base of the thorax. This peculiarity is 
readihv explained, as shown by Rees and Jenner, by reference to the 
normal relation which exists between the current of inspired air, the ex- 
pansion of the lungs, the descent of the diaphragm, and the firmness and 
resistance of the thoracic walls. If this relation be disturbed in any wa} r , 
the phenomena we are now considering may be produced. Thus if the 
diaphragm contract suddenly and violently, the lungs cannot expand with 
sufficient rapidity, and in order to prevent the occurrence of a vacuum, 
the thoracic walls must yield to the external atmospheric pressure at their 
least resisting part, which is, under normal conditions, at the base of the 
chest. The same result must occur, also, when the diaphragm contracts 
with only normal force, but when the calibre of the larynx is much nar- 
rowed, or again, when a considerable portion of lung tissue is collapsed. 
In the article on rickets, an affection in which the firmness of the chest- 
walls is much diminished, a full account will be found of the masterly 
manner in which Jenner has applied the above principles to the explana- 
tion of the deformities of the thorax so characteristic of that disease, 



42 INTRODUCTORY ESSAY. 

Auscultation and Percussion of the Lungs. — This portion of the 
examination of the sick child ought to be performed, if possible, whilst 
the patient is still and quiet. Unfortunately, however, it happens in a 
large majority of cases that the disturbance of position necessary to effect 
the exploration, and the presence of the physician, together with the 
irritability of nerves and temper occasioned by sickness, almost always 
cause more or less resistance on the part of the child, and produce violent 
screaming and struggling. In young infants we have to contend only 
against the instinctive resistance to an}" physical disturbance naturally 
attendant upon sickness and suffering. In older children, who have 
learned to distinguish between familiar and strange faces, and in whom 
the will has begun to act, there is added to the instinctive resistance of 
the infant an opposition of the most strenuous and annoying kind, founded 
upon the natural fear of a stranger, and upon a mental determination not 
to be interfered with or incommoded by the movements and changes of 
position necessary for a careful examination. 

For these reasons, the physical exploration of the chest in j'oimg sub- 
jects is often to be accomplished only with great difficulty, and in the 
midst of the most violent screaming, struggling, and contention. It is 
clearly important to avoid these obstacles if possible. This can only be 
done by the employment, on the part of the attendants and physician, of 
the most soothing, gentle, and patient management ; and in this way, let 
it be remarked, it can be done in a large majority of cases. The posses- 
sion by the physician of a quiet and yet decided manner, the power to 
interest and attract the child by entering with active sj^mpathy into its 
little amusements and pursuits, the skill to engage its attention by the 
exhibition of some book or toy, or the mere influence he may exert to 
calm its terror or excited irritability, by a soothing voice and gentle per- 
suasion, will, in many instances, overcome any resistance offered to the 
examination by children over two years of age. Nevertheless, in very 
young children, and in not a few that are older, no gentle means whatever 
will overcome opposition. Here the exploration must be made in the 
midst of struggles and cries, and though the results obtained will be less 
clear and positive than when the child is reasonable and obedient, a great 
deal of most valuable information can be acquired by a quick and dex- 
terous practitioner. The percussion can be made in the short intervals 
between the cries, or even during their continuance, and by placing the 
ear close to the finger by which it is performed, the sounds elicited can 
be very well heard and judged. The auscultation is more uncertain ; but, 
by watching intently the long and deep inspirations which immediately 
precede the violent cries, the presence or absence of rales, and their char- 
acters, the degree of freedom with which the air enters the lung, and the 
existence or non-existence of bronchial respiration, can, after some ex- 
perience, be ascertained and commented upon, so as to give considerable 
certainty to the diagnosis. 

The particular position in which to place the child, during the exami- 
nation, is of some importance. After the age of three and four years the 
position may be the same as that selected for the adult, if only the patient 



EXAMINATION OF THE LUNGS. 43 

be reasonable and tractable. When, on the contrary, the child resists, it 
should be taken on the lap of the mother or nurse, or else held in the 
arms, with the head inclined over one shoulder, while its back is presented 
to the practitioner. Infants within the year may sometimes be examined 
whilst engaged in the act of sucking ; but this is inconvenient, both from 
the constrained position, and from the circumstance that the inspirations 
are short and imperfect during that act. The French authors recommend 
that the very young infant should be laid, with its face downwards, across 
the hand of the practitioner, who is then to approach the back of the chest 
to his ear. We have found either one of the three following positions 
most convenient, as the case may be : the infant laid across the lap of 
the mother, with its face downwards, and the head hanging a little over 
one knee ; held in the arms, with the front of its body placed against the 
mother's chest, and the head tying over her shoulder; or, lastly, a favor- 
ite position of ours, placed in a sitting posture upon the lap, supported 
by one hand in front, and b}^ the other holding the occipital portion of 
the head. 

Auscultation should always be performed before percussion, because 
the latter generally alarms or annoj^s the child, and occasions crying, 
which of course would interfere more or less with the auscultation, were 
this performed after percussion. The auscultation should be made with 
the ear rather than the stethoscope, for the reason that the instrument 
terrifies the child, and also because it cannot, when the child resists and 
struggles, be kept in contact with the chest. Moreover, the instrument 
is unnecessary except for the examination of the upper portions of the 
thorax in front, and it had better, therefore, be dispensed with. 

Percussion is best made in children by using a finger of the left hand 
as the pleximeter, and b}^ striking with one finger of the right. One 
finger is quite sufficient to elicit all necessary sound in young subjects. 
The strokes should be light and distinct, consisting of short, quick, and 
gentle taps. 

To perform auscultation and percussion with success, the surface ought 
to be quite uncovered. The habit of examining the thorax through one, 
or several thicknesses of clothing, which some persons fall into, is a most 
careless one, and cannot but lead to uncertain and erroneous results. 

As a general rule, it is sufficient, in young children, to examine the pos- 
terior portion of the thorax. Doubtless, it is more accurate and artist ical 
to explore the whole chest, and this ought to be done in all obscure cases. 
But when the child is sick and suffering, when it is irritated and exaspe- 
rated by the presence of a stranger, or by coercion, and still more, when 
it is weak and exhausted by long or violent illness, it becomes of the 
greatest importance to shorten, as much as possible, the time occupied in 
the examination. For these reasons, it is well to be aware of the fact that, 
in nearly all inflammatory diseases of the lungs, the morbid changes affect 
first and most severely the posterior surfaces of those organs. This is 
thought to depend on the fact, that the child passes so large a portion of 
its time in the recumbent position as to cause the fluids of the body to 
gravitate towards the dependent parts of the lungs, and thus to determine 



44 INTRODUCTORY ESSAY. 

the beginnings of inflammatory action in that direction. Certain it is, 
be the explanation what it may, that it is rare to find the anterior surface 
of the lungs affected either with bronchitis, pneumonia, or pleurisy, the 
posterior surface remaining health}'. When, therefore, upon auscultation 
and percussion, no signs of disease are met with over the dorsum of the 
thorax, we ma}' feel pretty well satisfied that the lungs are health}'. 
Nevertheless, in all doubtful cases, the examination ought to be extended 
to the whole chest, in order to make what was, before this has been done, 
only a strong probability, a certainty. Whenever, also, it is important to 
ascertain the precise amount of disease in any serious or long-continued 
sickness, the front as well as the back part of the chest must be examined. 

The respiratory sounds are not of the same character precisely in the 
child as in the adult, and of this the physician onght to be aware. In 
children the vesicular murmur is stronger than in the adult, so that it 
assumes somewhat of a blowing or bronchial sound. It was in con- 
sequence of this peculiarity that Laennec gave it the name of puerile 
respiration, which, though a mark of health in earl}' life, is, at the period 
of maturity, an indication of a morbid change in some portion of the 
pulmonary parenchyma. It ought to be remarked, however, that in 
infants under two, and particularly in those under one year, the vesicular 
murmur is, in ordinary respiration, weaker than in adults; owing, no 
doubt, to the fact that the inspirations are short and imperfect, not dis- 
tending the lungs to their full capacity. When, however, from any cause, 
a sigh, a sudden disturbance, or the act of crying, a full and complete 
inspiration takes place, so as to dilate thoroughly the pulmonary struc- 
ture, the murmur becomes at once loud and strong, or, in other words, 
puerile, as in older children. 

The murmurs of inspiration and expiration bear the same relation to 
each other as in the adult ; the expiration being much shorter and feebler 
than the inspiration, though, at the same time, it, like the inspiration, is 
louder than in the adult. In some instances, however, and especially 
over the posterior inferior and lateral regions of the thorax, no sound 
whatever is heard during the accomplishment of the expiration. This 
absence of sound during expiration is the more apt to be met with in 
proportion as the child is younger. 

When a young child is made to breathe forcibly and rapidly, the respi- 
ratory sounds assume certain characters, even in perfect health, which 
might mislead an inexperienced observer. The inspiration is short, loud, 
and hard, so as to assume somewhat of a blowing character, resembling 
not a little the sound of bronchial respiration. At the same time, the 
expiration becomes louder also, and longer, which two circumstances, 
rude or even blowing inspiration, with loud and somewhat prolonged 
expiration, may very well deceive a young or careless practitioner. 

The respiration is most clear and characteristic over the anterior, 
lateral, and posterior inferior regions of the thorax. Over the origin of 
the larger bronchia, that is to say, in the interscapular region, the respi- 
ration is very strong, so as to resemble very closely bronchial blowing. 
Here, also, the expiration is often very marked ; it is sometimes heard as 



EXAMINATION OF THE LUNGS. 45 

long, or even longer than the inspiration. Over the scapulas, the sound 
of respiration is always feebler than elsewhere, except in the precordial 
region, from the interposition of the scapulas and of thick muscles be- 
tween the ear and the lung. 

Percussion yields a much louder and more sonorous sound in children 
over two years of age than in adults, — a circumstance always occurring 
coincidentally with the presence of puerile respiration, and dependent on 
the fact that the function of respiration is, at that age, very active, and 
the lungs therefore filled to their utmost capacit}^ with air. In infants 
under two years of age, the sonorousness varies to a considerable extent 
in the same child. When the respiration is, as it usually is, gentle and 
easy, the inspirations being rather feeble and incomplete, the amount of 
air contained in the lungs will be somewhat deficient in comparison with 
what their cells might contain, and the sound yielded upon percussion 
will necessarily be rather dull and insonorous. When, on the contrary, 
the respiratory process is quick, active, and energetic, from any cause, so 
as to give rise to the auscultatory phenomenon called puerile respiration, 
the percussion will be loudly sonorous, as it is in the later periods of child- 
hood, owing to the thorough dilatation of all the air-cells, and the con- 
sequent presence in the thoracic cavity of a large amount of air. 

The sonorousness of the thorax is different in different parts in chil- 
dren, as in adults. In front, the percussion is most sonorous from just 
beneath the clavicle on the right side down to one or two inches below 
the nipple, where it gradually becomes dull, owing to the position of the 
liver. On the left side the sonorousness is modified by the presence of 
the heart in the manner already mentioned. Below the precordial region 
we again have pulmonary resonance down to the sixth or seventh ribs, 
below which is heard the tympanitic sound of the stomach. 

Behind, the sound is very dull above the spine of the scapula, and con- 
siderably so over the scapula beneath its spine. Over the interscapular 
space it is clear and strong, and more so in the lower than in the upper 
half. Beneath the inferior angle of the scapula, likewise, it is clear and 
full, until we approach the inferior margin of the thorax, where it is 
dulled, even above the lower edge of the lungs, by the presence beneath 
of the liver on one side and of the spleen on the other. Over the right 
side the dulness begins a little higher than over the left, in consequence 
of the greater bulk of the liver than of the spleen. 

The lateral regions are very resonant in their upper portions, but be- 
come dull as we approach the liver on the right side and the spleen on 
the left. On the left side the pulmonary sound is often entirely eclipsed 
by a t3^mpanitic resonance occasioned b}^ the presence of gas in the 
stomach. 

In practising percussion in children it is necessaiy to strike gently, 
because, from the great natural sonorousness of the chest in early lite, 
any considerable force would bring out so much sound as to prevent the 
recognition of a degree of dulness which might readily be perceived by 
the use of more gentle blows. It is necessaiy always to compare the two 
sides together as in adults, since this often leads to the detection of a de- 



46 INTRODUCTORY ESSAY. 

gree of impaired resonance which might be otherwise inappreciable. Yet, 
and the physician ought to be well aware of this, the comparison of the 
two sides is not quite so useful in young as in mature subjects, because 
of the fact that the diseases in which the differential comparison is most 
important, pneumonia and pleurisy, are more frequently double than in 
adults. It becomes, for the same reason, very important to compare the 
upper and lower portions of the thorax behind, since we ma}^ assure our- 
selves of the existence of d ulness below, of which we were before doubtful, 
by the fact that the sound is less sonorous in that region than above, 
which is, as already stated, the very opposite of the healtlry condition. 

Examination of the Abdomen. — It is often very important to ascer- 
tain, Ivy palpation, the form, size, and degree of tension of the abdo- 
men, the presence or absence of effusions within its cavity, and the con- 
dition of the organs which it contains ; to learn by percussion the degree 
of resonance which it affords ; and, lastly, to find by pressure whether it 
be unnaturally tender to the touch or not. By a careful inquiry into 
these various points, and a proper comparison between them and the 
rational symptoms presented b}' the patient, we shall be able to discover 
the existence of tumors, of hypertrophied organs, of unusual develop- 
ments of gas in the intestines, of dropsical effusions, of enlarged and 
hardened mesenteric glands, of gurgling, and of soreness on pressure, 
caused by inflammation of some of the contents of the cavuVy. The ex- 
amination should be made, if possible, whilst the child is still and com- 
posed. It is best, therefore, to perform it before auscultation and per- 
cussion, in children who are old enough or amiable enough to be will- 
ingly quiet, since the length of the examination of the thorax often 
wearies out their patience, and they refuse to submit to further inspec- 
tion ; whilst, in infants and in children who obstinately resist the exami- 
nation, it matters little at what particular period it is attempted, since it 
must be done at last in the midst of cries and general agitation. It is, 
at all times, a difficult and not very useful examination, unless the patient 
consents to it freely and without fear. It is very necessary, therefore, to 
resort to every means to obtain this quiet consent. In children over a 
year old, this condition is to be obtained only during deep sleep, during 
the act of nursing, or, when the patient is awake, by so pleasing and 
attracting its attention b}~ toys, by soothing voice and manners, as to 
cause it to forget what is passing. The reasons why the examination is 
useless, unless made during a state of calm, are very obvious. In the 
first place, the contractions of the abdominal muscles give to the walls of 
the abdomen such a degree of hardness and rigidity, that it is impossi- 
ble to learn anything in regard to the state of the parts within, except 
merely what can be learned by percussion ; and, in the second place, no 
acuteness of perception will enable us to distinguish between the cries of 
anger and fright, and those that may proceed from pain occasioned by 
pressure. 

M. Yalleix recommends a plan in the case of young infants, by which 
tenderness on pressure may very generally be recognized. It is as fol- 
lows : he carries the child, carefully sustained in the arms, suddenly be- 



EXAMINATION OF THE MOUTH AND THROAT. 47 

fore a bright light, either that which pours in at a large window during 
daylight, or that of a bright artificial light at night. The infant, whose 
greatest pleasure consists in gazing at a bright light, almost always ceases 
to scream and becomes perfectly quiet while thus attracted. Seizing this 
opportunity, the physician should pass his hand under the clothes, and 
applying it directly over the cutaneous surface, he may first learn, by a 
rapid palpation, the general characters of the abdomen, and then ascer- 
tain by sudden and decided pressure whether it be abnormally sensitive. 
If the pressure gives pain, the infant will cry out at the moment, while, 
at the same time, a sudden contraction of the countenance will assist to 
show the perception of some painful sensation. Should the infant, on 
the contrary, continue to gaze fixedly at the light, without noticing the 
manoeuvres of the physician, it is fair to conclude that there is no inflam- 
matory tenderness present. 

Examination of the Mouth and Fauces. — In all obscure attacks of 
sickness occurring in young children, and even in those who have attained 
to the faculty of speech, the physician ought to be most careful to inspect 
the condition of the mouth and fauces, since not a few cases of fever 
which seem at first view inexplicable, are at once made plain by this 
simple exploration. We were once called to see a child three years of age, 
who had been sick three days with fever, thought by intelligent and edu- 
cated parents to depend on gastric derangement. A single look into the 
throat showed it to be completely clogged up with pseudo-membranous 
exudation, whilst a slight hiss in the inspiration, and a husky voice, 
declared that the same fatal product was just entering the larynx. The 
time for successful action had slipped by; the patient died two daj T s after 
in the agonies of slow croup. On another occasion we were called to 
take charge of two children in one family who had been ailing several 
days with feverish symptoms, loss of appetite, languor, and some com- 
plaint of sore throat. In both Ave found the fauces covered with plastic 
deposit, and both died a few clays after of membranous croup. Some 
years ago we attended a child between five and six y ears old, for a period 
of four days, with irregular fever, some vomiting, total anorexia, languor, 
indisposition to play, and rare complaints of pain in the chin and neck, 
that were not mentioned to us by the attendants, so that all the time we 
had the idea that the attack was one of gastric embarrassment. Greatly 
to our amazement and consternation, the mother informed us on the fifth 
day that she had seen something white in the throat, and upon examina- 
tion we found both tonsils covered with whitish exudation. Happily the 
exudation was still confined to these glands, and we were able by appro- 
priate treatment to prevent its further extension. 

In croup, also, in whatever form it may make its attack, the fauces 
ought to be closely watched, in order to know by the presence or absence 
of false membrane, the probability or improbability of the case being one 
of the membranous kind. In scarlatina and measles, especially in the 
former, the throat ought to be examined each clay, to ascertain its precise 
condition, and particularly to learn whether there be present any dis- 
position to membranous, ulcerative, or gangrenous angina. 



48 INTRODUCTORY ESSAY. 

In young infants, also, the month requires a thorough examination 
from time to time in all their ailments, and especially in their digestive 
diseases, since they are liable to thrush, to aphthae, and in chronic and 
debilitating maladies, to gangraena oris. In teething children the act of 
dentition requires that the mouth should be inspected occasionally in 
order to ascertain the state of that process, and to detect the existence 
of the form of stomatitis called ulcerative, which generally occurs between 
the ages of one and five or six years. 

The mouth can be readily examined by pressing upon the chin with 
force sufficient to cause the child to separate the jaws. In the young 
infant this very generally produces crying, during which the mouth is 
widely opened, and the state of the cheeks, lips, gums, and tongue can 
be perfectly well seen. In an older child, who refuses to open the mouth, 
or to keep it open, the handle of a smooth silver spoon is the best in- 
strument to emploj* by which to effect our propose. 

The throat cannot be well seen at any age, except by depressing the 
base of the tongue, which is best done b}~ means of a spoon-handle, as 
above directed. When a child refuses obstinately to open the mouth, 
and resists with violent struggles, it should be taken on the lap of a strong- 
assistant, with the back of its trunk resting against the chest of the as- 
sistant, whose arms should restrain, by being crossed over the body and 
limbs of the child, its more vehement movements. Another assistant 
must hold the head of the child stead}*, whilst the physician obliges it to 
open the mouth, either b}~ closing the nostrils with the fingers, or b} T 
slowly and gently, but firmly, insinuating the handle of the spoon between 
the teeth. After the spoon has once been passed over the tongue there 
is seldom any difficulty in obtaining a good view of the fauces. 

The introduction of the finger into the mouth is of some use as a diag- 
nostic means in the case of infants. It informs us of the temperature of 
that cavity, of the state of its secretions, and, consequently, of its diyness 
or humidity, and of the disposition and ability of the infant to suck. 
When an infant is in good health, it will almost always seize the finger, 
when this is placed in the mouth, and suck vigorously for some instants. 
It will do the same when it is only ailing with some slight malady, and 
in the early stage of more dangerous diseases. But, in severe and threat- 
ening illness, the infant either refuses to suck upon the finger at all, or 
does so only for an instant. When the mouth is irritated or inflamed, as 
in the various forms of stomatitis, the child will open the mouth and cry, 
and make no attempt whatever at suction. In stupor, and especially in 
coma, but little attention is paid to the finger, the infant being generally 
unconscious of its presence. 

By watching the child when put to the breast, we may acquire nearly 
the same information as that just referred to, except that the child would 
naturally make a greater effort to seize the nipple than the finger, and 
would therefore nurse, even though the act of so doing were painful, under 
circumstances in which it might refuse to grasp the finger at all. The 
refusal to nurse, or the nursing but little at a time, may depend on other 
causes, however, than sore mouth. It often depends on some anginose 



VOMITING AND DISCHARGES BY STOOL. 49 

inflammation. When this is the case, it may be suspected from the pecu- 
liar gulping manner in which the child swallows, and from the fact that 
swallowing often causes fits of coughing. It is caused also by dyspnoea. 
An infant laboring under severe oppression from pneumonia, bronchitis, 
or an}* other cause, never sucks well and steadily, but rather by fits and 
starts. The nipple is seized often with avidity, and two or three swallows 
are made in quick succession ; then follows a pause to regain the breath, 
and then again the eifort of deglutition. In a few cases attended with 
very great dj^spncea, that we have seen, the patients have been able to 
swallow only once or twice without pausing, and even then with very 
great difficulty. 

Manner of Taking Drinks. — The remarks just made as to the infer- 
ences to be drawn from the manner in which the infant sucks, will apply 
also to the mode iu which both infants and older children drink. A young 
child drinks continuously, without stopping to breathe. If, however, it 
have any disorder which accelerates the respiration, it will, after drink- 
ing a few mouthfuls, cease, jerk its head away from the cup or spoon, 
breathe irregularly and hurriedly, and cough. These symptoms ought 
to call attention to the respiratory organs. So, if a child, whose breath- 
ing is not oppressed, nevertheless drinks with difficulty, slowly, at in- 
tervals, and apparently with pain, there is reason to suspect some imped- 
iment in the pharynx, and the fauces ought thereupon to be carefully ex- 
amined. 

"We maj' learn also from the manner of drinking whether the child is 
thifsty or not. When it drinks often and with avidity, and yet has a dry 
mouth, it is evident that there is very great thirst. 

Yo3jiting and the Discharges by Stool. — The physician should 
never think his examination of a sick child concluded until he has inquired 
as to the occurrence of vomiting, and as to the state of the discharges by 
stool, ^sot only, indeed, should he inquire as to these symptoms, but he 
ought by all means to inspect personally the appearance of the matters 
ejected. This is especially important in regard to the dejections, since 
no description of a mother or nurse, however intelligent, can impart to 
the physician the precise and accurate idea of the state of those discharges 
which even a very rapid inspection would give him. 

Vomiting is of very frequent occurrence in infancy and childhood. 
Owing to the fact that the stomach is much less curved in its shape than 
in the adult, and that the oesophagus enters the organ close to its left ex- 
tremity, vomiting and regurgitation take place with great readiness, and 
are, therefore, very common S3*mptoms in the diseases of early life. 

The young practitioner must beware lest he regard all kinds of vomit- 
ing in the infant as the result of disease. The nursing child is very apt 
to vomit, even when in the most perfect health, especially if it be suckled 
at an abundant breast. This kind of vomiting, however, may be readily 
distinguished from that which depends on some morbid state of the health, 
by the circumstance of the infant's ejecting nothing but the milk which it 
has swallowed, either just as it was drawn from the mother, or slight ly 
curdled, and by the fact that it suffers no inconvenience whatever from 

4 



50 INTRODUCTORY ESSAY. 

the act, — neither airy violent effort, languor, paleness, nor faintness. And 
yet we have known a 3'oung practitioner to prescribe antacids and ab- 
sorbents to correct this kind of vomiting, which is most plainly an act of 
nature kindly intended to rid the infant of any excess of food it may have 
imbibed. 

In older children also, vomiting not imfrequentry occurs as a conse- 
quence of over-distension of the stomach with food. When, therefore, 
after vomiting, a child seems relieved and comfortable, when any un- 
pleasant symptoms that may have existed prior to it moderate or disap- 
pear afterwards, it is fair to conclude that the act has been beneficial, 
and wrong to regard it as the signal of a necesshVy for giving medicine, or 
for regarding the child as a patient, except insomuch as to watch lest it 
be sick as an after-consequence of having had the digestive power over- 
tasked. 

Frequently repeated vomiting, attended with retching and effort, and 
with paleness and exhaustion, or with fever, always indicates some con- 
siderable derangement of the health. It is impossible to ascertain the 
precise cause of such vomiting, except by a proper consideration and 
comparison of all the sjmrptonis the child may present. The cause may 
be in the stomach itself, consisting of an inflamed state of the organ, or 
it ma}' be a simple indigestion without any inflammatoiy condition what- 
ever ; it ma} T be that the cause lies in the intestine, being some inflamma- 
tion, functional disease, or obstruction of that part; it maj^be pneumonia 
or pleurisy ; it ruay be the approach of some of the eruptive fevers ; or 
last, and most serious of all, the cause may be some commencing lesion 
of the brain, which, though as yet determining no proper cerebral symp- 
toms, shall perhaps be destined, by its inevitable progress, to end the 
patient's life. The detection of the particular causative condition, in any 
of these forms of vomiting, can be arrived at only by a careful study of 
the whole constitution of the patient, both through the rational symptoms 
that may be present, and by a thorough inspection of the different systems 
of the body by means of the physical methods of diagnosis. 

The rule to examine with his own eyes the napkins or cloths of the 
child, ought never to be forgotten by the practitioner, when there is any 
reason to suppose that the alimentary functions are at all deranged. The 
number of the stools in the twenty-four hours ought also to be ascer- 
tained, not loosely and carelessly, but precisely and with certainty. 
Without a close attention to these two precautions, it is impossible for 
the physician to obtain really useful and exact notions in regard to the 
nature of the disorder he is called upon to treat, or to judge of the de- 
gree of severity of the attack. 

We shall not attempt to consider in this place, either the various un- 
natural appearances of the matters vomited, or ejected by stool, the 
amount of those substances, or the frequency with which the discharges 
take place, since these various circumstances can be treated of in the 
manner they require, only when we come to study separately the diseases 
of which they form a part. 



CONCLUSION. 51 

TTe shall here conclude our remarks upon the methods to be pursued 
in the clinical exploration of the diseases of children. We have only to 
add the wish that those who shall honor them with their perusal, may 
find them of some real assistance in their subsequent studies of the affec- 
tions of early life. They are intended, of course, chiefly for the student 
and young practitioner; but we cannot help hoping that they may possi- 
bly prove useful to some who have spent a longer time in the profession, 
but who have never, perchance, given any particular attention to the best 
modes of investigating the diseases of infants and children. 



CLASS I. 

DISEASES OF THE RESPIRATORY ORGANS. 
CHAPTER I. 

DISEASES OF THE UPPER AIR-PASSAGES. 

SECTION I. 

DISEASES OF THE NASAL PASSAGES. 

ARTICLE I. 

CORYZA. 

Definition; Synonymes; Forms; Frequency. — Ccnyza is inflamma- 
tion of the mncons membrane lining the nasal passages^ It is called in 
common language, cold in the head, or snuffles. Underwood describes 
one variety of it under the title of coiyza maligna, or morbid snuffles, 
which, he sa} T s, is very different from and a far more serious disorder than 
what is usually called snuffles. Dewees makes no reference to it. Eberle 
describes it under the title of coryza. He doubts whether coryza maligna 
ever occurs in this country, and takes his account chiefly from Under- 
wood and Denman. 

We shall describe three forms of the disease, — the simple, or mild, the 
severe, and the chronic. The severe form includes purulent and pseudo- 
membranous coiyza. Simple coryza is very common at all ages ; it occurs 
frequently as a distinct disorder, but still more frequently in connection 
with laryngitis, bronchitis, pneumonia, measles, scarlet fever, &c. The 
severe form of coiyza is that which has been called by Underwood coiyza 
maligna, or morbid snuffles. Purulent and pseudo-membranous coryza 
rarely occur as idiopathic affections, but are almost invariably connected 
with angina or other diseases. We met with one case, however, of the 
purulent form, unaccompanied by angina or other disease, in 1841, in a 
child seven weeks old. The case proved fatal. We saw another fatal 
case of the same form, connected with simple angina, in 1846, in a child 
five weeks old. Besides these two cases, we have met with four others of 
the pseudo-membranous variety, accompanied by simple angina, in chil- 
dren between two and six years of age, all of which terminated favor- 
ably. The two varieties of the disease occur, however, as already stated, 
much the most frequently as secondary affections in the course of other 
diseases, particularly measles, scarlet fever, pseudo-membranous angina, 



CORYZA — SYMPTOMS. 53 

etc. TTe shall not attempt in the present article to treat particularly of 
the cases which accoinpan}' the eruptive fevers. 

Causes. — The only clearly evident cause of simple primary coryza, in 
most cases, is chilling of the bocly. Insufficient dress, — a very common 
error in this country, — too low a temperature of the nursery, and ex- 
posure to bad weather, ma}' often be discovered to have been the causes 
of the attack. 

The causes of the disease, in the two cases of purulent coryza above 
referred to, were unknown. In one the nurse remarked a slight discharge 
of blood from the nose soon after birth, and the coryza elated from that 
time. In the other, the patient, a feeble child, was attacked when two 
weeks old without any appreciable cause. The four cases of the pseudo- 
membranous form occurred in 1845 and 1846, during an extensive preva- 
lence in this city of severe scarlet fever, measles, and pseudo-membranous 
angina and laryngitis, which makes it probable that they depended upon 
the epidemic constitution of the atmosphere. The cases of MM. Rilliet 
and Barthez coincided generally with primary or secondary purulent or 
pseudo-membranous angina. From the account given by Underwood of 
coryza maligna, there can be little doubt that it was epidemic when ob- 
served by himself and Denman. The latter author states that in con- 
nection with the coiyza there was a general fuluess of the throat and 
neck externally ; that the tonsils were tumefied, and of a dark red color, 
with ash-colored specks, and in some cases, with extensive ulcerations ; 
and that some of the children swallowed with difficulty : all of which 
symptoms clearly point to severe concomitant angina. 

Anatomical Lesions. — The Schneiderian mucous membrane is found 
reddened uniformly, or in points, rough, thickened, and sometimes soft- 
ened. When pseudo-membrane is present, it exists either in fragments, 
or lines the whole extent of the nasal passages, and is mixed with mucus 
or muco-purulent fluid, in greater or less quantity. 

Symptoms. — The symptoms of simple coryza are sneezing, dryness of 
the nose at first, soon followed by discharge, which is very small in quan- 
tity in the beginning, and more abundant afterwards, and more or less 
disturbance of the respiration. It is only in young infants that this form 
of coryza is a disorder of any consequence in itself. In older children it 
never injures the health by its own action ; it is of importance merely as 
the sign that a cold has been taken, and ought to be regarded as a hint 
given by nature of the necessity of guarding the child more carefully in 
future. But, in infants at the breast, and very young children, it assumes 
much greater importance from the very considerable obstacle it opposes 
to the act of respiration. At this early age, in fact, coryza becomes a 
serious and even dangerous disease. If primary, it causes great distress 
and disturbance to the child, interrupting its sleep, interfering with the 
act of nursing, and, in some instances, so impeding the function of res- 
piration, as to bring on slight, and more rarely, dangerous asphyctic 
symptoms. It may, undoubtedly, occasion, in weak and debilitated chil- 
dren, more or less extensive collapse of the lungs, an accident which will 
explain the imperfect performance of the hematosic function in some 



54 COKYZA. 

cases, where the only evident disease is this apparently insignificant one 
of coryza. 

When simple coryza exists in connection with bronchitis and pneu- 
monia, it adds to the severity of those diseases. In children over three 
or four years old, and particularly in those who are vigorous, it seldom 
gives any serious trouble. But in young infants, and in weakly children 
of any age, its influence upon the symptoms is often very marked. The 
effort to breathe through the nasal passages, when they are partially or 
wholly occluded by the inflammatory swelling of their lining mucous 
membrane, or b} T abundant and viscid secretions, fatigues, and wears 
away the strength of the child, exhausts its energies, and renders it less 
able to resist the pressure of the sickness. But not only this ; — as in 
primary coryza, the entrance of air into the lungs is impeded, and the 
hematosic function is thereb}?- interfered with, while at the same time, 
the existence of an obstacle to the full inspiratory movement, in addition 
to that which exists in the lungs themselves from bronchial or pneumonic 
disease, cannot but assist in the production of that collapse of the pul- 
monary tissue, which has been found of late years to coincide so often 
with the bronchitis and pneumonia of 3 T oung children, and especially 
with the former. 

The reason why coryza causes so much difficulty in young children is, 
that they persist in the effort to breathe through the nose in spite of the 
obstruction of the nasal passages. They seem to do this instinctively, 
not, apparently, having the power to carry on the act of respiration 
through the mouth, or but for short periods only at a time. The con- 
stant struggle to force the air through the nose, and the necessarily 
smaller quantity that reaches the lungs, are undoubtedly the two chief 
causes of the sjunptoms above described as occurring in the corj^za of 
children. 

Severe Coryza begins with sneezing and stoppage of the nostrils, 
soon after which the discharge, which is the pathognomonic symptom of 
the disease, makes its appearance. This consists of serous or mucous 
fluid in greater or less abundance, usuallj 7 of a 3 T ellowish color, and which, 
at first thin and without odor, becomes afterwards thicker and often puru- 
lent, with a peculiar, unpleasant, but not fetid odor. In other cases, on 
the contrary, and especially when the pseudo-membranous exudation is 
present, the discharge is thin, and often contains small granular particles, 
which seem to be the detritus of the false membrane, while at other times 
it is ichorous or even bloody. When false membrane is present, it can 
often be seen, upon examination of the nostrils in a strong light, to cover 
the mucous membrane in the form of thin adherent layers of a yellowish- 
white color. The alae nasi, and sometimes the whole extremity of the 
nose, are red and swelled, and the skin, which is tense and shining, pre- 
sents an erysipelatous appearance. The upper lip is generally reddened, 
irritated, swelled, and sometimes excoriated, by the nasal secretions. 

The respiration is generally difficult, nasal, and snoring. When the 
nasal passages are nearly or quite filled with the secretions, the child 
being no longer able to breathe through them as in health, is compelled 



SYMPTOMS. 55 

to keep the month open. This is exceedingly inconvenient to children 
of all age?, as it causes great dryness and stiffness of that cavity, and of 
the tongue and throat, and in very j'omig infants, who instinctively re- 
spire almost exclusively through the nostrils, it is attended with snch 
violent efforts, as to be a chief or perhaps sole cause of the fatal termina- 
tion of some cases. In one instance that we saw, the child was seized 
with attacks of suffocative breathing, which threatened fatal asphyxia, 
whenever the passages became much impeded. Under these circum- 
stances the cleansing of the passages with a brush would afford complete 
relief, and, for a time, the little thing would appear to be quite well. 
Finally, however, death occurred in one of the attacks of dyspnoea, from 
sudden serous effusion into the lungs. The difficulty of respiration is 
greater, as we have stated, in proportion as the child is younger, and 
depends on the physiological fact already referred to, that at a very early 
age, respiration is performed almost solely through the nostrils, and that 
the child seems incapable of keeping the mouth open, in order to com- 
pensate for their closure. We have never observed cough except in cases 
accompanied by angina. Epistaxis occurred in two cases of the pseudo- 
membranous form, in children between three and five } r ears of age. The 
bleeding recurred on several occasions, but ceased so soon as the coryza 
was cured. Infants refuse the breast when the passages are much clogged, 
or suckle with great difficulty and at long intervals. 

The character of the general symptoms depends much more upon the 
accompanying disease, in older children, than on the coryza itself, and 
it is unnecessary therefore to dwell upon them. In the two infants ob- 
served by ourselves, the principal symptoms were, in the case unaccom- 
panied by angina, restlessness, weakness, emaciation, dry, harsh, and 
wrinkled skin, and violent attacks of dyspnoea ; and in the other case, 
in which angina was present, there were added to these, fever and som- 
nolence. The duration, as observed by ourselves, in the two cases oc- 
curring in infants, was between two and three weeks, in the one unattended 
by other disease, and six days in the one accompanied by angina. In 
the other four cases, which occurred in older children, the duration of 
the attack depended on the form and degree of the attendant angina. In 
one case it became chronic, and was accompanied by ulceration of the 
nasal passages. MM. Rilliet and Barthez state that they saw a child two 
years old die in three days, and another of three years in the same time ; 
but as one of these cases was complicated with angina and croup, and 
the other with pseudo-membranous angina, it is clear that the rapid death 
depended rather on the accompanjdng disease, than the coryza itself. 

The prognosis must depend on the age of the child, and the form of 
the attack. Simple coryza is never dangerous except in very young in- 
fants, and rarely in them. When, however, it occurs in a delicate infant, 
and is accompanied with either sufficient turgescence of the nasal mucous 
membrane, or with enough viscid secretion, to cause a nearly complete 
occlusion of the nasal passages, the effort to breathe through the nose. 
and the diminished quantity of air that reaches the lungs, will sometimes 
give rise to great and dangerous exhaustion, or to partial or fatal as- 



56 CORYZA. 

phyxia. In older children this form of the disease is never scarcely more 
than an anno}*ance. 

When simple coryza occurs in connection with other diseases, whether 
thoracic inflammations, angina, or measles, it always adds, and sometimes 
most seriously, to the difficulties of the patient, since the effort to breathe 
through the obstructed air-passages must assist to exhaust the life-forces, 
while at the same time a certain amount of the blood in the lungs, which 
ought to be exposed at each inhalation to the inspired air, is deprived of 
this necessary contact by the fact, that less than the natural quantity of 
air is drawn through the nasal passages at each expansion of the chest. 

The purulent and pseudo-membranous forms of coryza are always dan- 
gerous, whether the}* occur alone, or as a part of other diseases. The 
two cases of idiopathic membranous coryza in infants that came under 
our observation, both proved fatal. The four cases in older children re- 
covered without any difficulty. When they occur in connection with 
pseudo-membranous angina, or in the course of scarlet fever, the prog- 
nosis will of course depend very much on that of those diseases. 

Chronic Coryza. — Under this title we shall describe as succinctly as 
possible a form of inflammation of the Schneiderian membrane, of which 
we see a good many examples. It is characterized rather by swelling 
and thickening of the mucous membrane as far as this can be seen, and 
by an accumulation of scabs and crusts, causing obstruction to the pas- 
sage of the air, than by a discharge. The secretions are, in fact, not 
much increased in quantity be} T ond their natural amount, but they con- 
sist of very thick mucus, or the}* are purulent in character. 

We have met with this form of disease generally in children over two 
years of age, and from that period up to puberty. Its principal cause 
has alwa}*s seemed to be some faulty state of the general health, some 
constitutional dyscrasia. Like the keratitis and chronic otorrhcea of 
children, it makes its appearance without any evident exciting cause 
whatever, or it follows an acute attack of catarrhal inflammation from 
cold, or an attack of measles, scarlatina, or epidemic angina. On one 
occasion, we met with it in three out of a family of four children. Though 
it is unquestionably very apt to occur in scrofulous children, its presence 
is not necessarily a sign that the patient is of scrofulous habit, since we 
have seen it in families in which there was no taint of that disease, and 
have known a good many of those affected by it to recover perfectly, and 
show no subsequent symptoms of the scrofulous or tubercular cachexia. 
Its chief efficient cause appears to be a low state of the general health, 
the blood being more or less markedly anemical, and the nutrition of the 
body imperfect. In addition to the above conditions, it must also be 
borne in mind, as a fact of the utmost importance, that this form of 
coryza occurs frequently as a symptom of constitutional syphilis. 

The chief symptoms of this form of disease are of a local character. 
The breathing is at all times more or less nasal and embarrassed. Even 
in the waking state, the child will sometimes attract attention by the 
noisy and slightly oppressed character of its respiration, while when 
asleep the obstruction to the passage of air through the nasal passages 



TREATMENT. 57 

will be so great as to give rise to symptoms which, though, not alarming, 
are most annoying to those around. The obstruction to the passage of 
air through the nasal passages produces snoring or hissing sounds, which 
are sometimes so noisy as seriously to disturb those sleeping in the same 
apartment. This obstruction also obliges the child to make much greater 
muscular efforts than in the healthy state, to supply the thorax fully with 
air, so that the sleep, instead of being quiet and easy as in health, is 
broken and disturbed b} T the unusual play of the muscles, and by the 
disordered internal sensations caused by the reaction upon the nervous 
centres of a circulating fluid less thoroughly decarbonized than it should 
be. The child tosses and rolls, sighs and moans, or it cries out in its 
sleep, or it wakes suddenly and frequentVv. 

When the nasal passages are examined by a full light, they will be seen 
to be obstructed in two ways : b} r a thickened and injected state of the 
mucous membrane, and by the presence in them of scabs, or of more or 
less inspissated masses of mucus or muco-pus. The mucous membrane is 
also redder and more highly vascular than natural, and sometimes exhibits 
an appearance in some points as though excoriated or slightly eroded. 
There is seldom, indeed rarely, any considerable amount of fluid secre- 
tion, as in acute coiyza; the secretions are so much more viscid than 
usual that they desiccate in the passages and form scabs and crusts. Not 
unfrequently the surfaces become so irritable as to bleed very easily. 
The act of blowing the nose, a rude touch, or a blow, will cause a con- 
siderable discharge of blood, and this is often the sjanptom for which 
the practitioner is particularly consulted. The voice of the child is 
usually characteristic ; it is nasal ; and when the obstruction is consider- 
able this becomes a marked symptom. 

The general appearance of the patient almost always shows a deterio- 
rated state of the general health. His color is too pale ; the skin is 
muddy ; the expression is languid ; the tissues are more flabby and flaccid 
than they ought to be ; and the movements are less brisk and prompt than 
in full health. Such patients wake from their sleep less refreshed than is 
natural ; their appetite is often capricious and poor ; and the digestive 
and nutritive functions are impaired. The tongue is often flabby in its 
texture, pale, and more or less furred, the bowels are irregular, and the 
discharges often scanty, and of an unhealthy color and smell, or there 
are alternations of diarrhoea and constipation. 

The duration of this form of coryza is very indefinite. Under the most 
patient treatment, it often lasts for many months, and even when cured is 
very apt to return with or without apparent exciting causes, so that we 
have known it to last for several years. 

Treatment. — Simple coryza requires no treatment in children over two 
years of age, except attention to hygienic conditions. Young children 
may often be preserved from attacks of spasmodic laryngitis and bron- 
chitis, by calling the attention of the mother to the strong tendency 
which exists during infancy and childhood to the extension of disease, 
and advising, in cases of coryza, that the child should be secluded in the 
house, or else very warmly clothed if sent out. 



58 CORYZA. 

In young infants, even the mildest coryza gives trouble, by obstructing 
the full freedom of the respirator}' act, by interfering with the suckling, 
and by the restless and broken sleep which it induces. In such cases, all 
the treatment required is to keep the child warm, and to clear the nasal 
passages, and at the same time lubricate them, by the occasional intro- 
duction of a camel's hair pencil charged with glycerine, or sweet oil. 

When the coryza is more severe, so as to interfere a good deal with the 
respiration, it is necessary to make use of the brush frequently, to ad- 
minister a warm foot-bath once or twice a day, and to give a few drops 
of syrup of ipecacuanha, with sweet spirits of nitre, every two, three, or 
four hours. In such cases, the late Dr. Charles D. Meigs was in the habit, 
for maii3 T years past, of directing a flannel cap to be put upon the child, 
and kept there for two or three days ;— a simple, and often most effectual 
mode of treatment. The cap should be removed after two or three days, 
so soon as the coiyza is relieved, as otherwise the child is apt to become 
so much accustomed to it, as to take fresh cold when it is removed. 

In infants laboring under purulent or pseudo-membranous coryza, the 
indications of treatment are to remove the secretions as they collect, and 
to subdue the inflammation of the mucous membrane by which they are 
produced. The first indication ma} r be fulfilled by means of a brush made 
of long camel's hair, hy throwing water from a small syringe into the 
nasal passages, or, when the discharges are thin and fluid, by blowing 
strongly into the nostrils, whilst the tongue is depressed by a finger in- 
troduced into the mouth, so as to allow the secretions to pass out of the 
posterior nares into the fauces. 

The second indication is to be fulfilled chiefly by the application of 
solutions of alum, nitrate of silver, sulphate of zinc or copper, and by 
insufflations of different substances in powder. The best application is 
probably the solution of nitrate of silver, which may be made of the 
strength of five or ten grains to the ounce, or stronger, to be made use 
of several times a day, with a brush. We have also employed injections 
consisting of solutions of alum, of from three to six grains to the ounce. 
It is recommended by MM. Eilliet and Barthez to make insufflations of 
powdered gum and alum, or of gum and calomel in equal parts, several 
times a day. There is, however, it seems to us, an objection to this 
method of treatment, especially in infants, — which is, that the powders 
would necessarily tend to increase the obstruction which already exists, 
to breathing through the nose. It has been proposed also to apply a few 
leeches to the mastoid process, or over the frontal sinuses ; but it seems 
to us that this could scarcel}' ever be advisable. 

In the form of the disease accompanied with angina, an essential part 
of the treatment must be that of the throat-affection. This will be con- 
sidered in another place. 

The treatment of chronic coiyza must be twofold : general and local. 
The most important points to be attended to in connection with the gen- 
eral treatment are the clothing, the diet, and the administration of tonics 
and alteratives. The clothing ought to be warm during the cold seasons 
of the year. Flannel, as a general rule, ought to be insisted upon. The 



TREATMENT. 59 

arms and neck must be covered, and the legs should never be exposed, 
after the very mistaken fashion amongst many persons of the present 
day. The diet ought to be strengthening and nutritious. Fresh meats, 
milk, bread, and good butter, and the plainer vegetables, ought to be 
urged upon the child. If necessary, some authority must be made use of 
by the parents to induce the patient to take a sufficient quantity of these 
plain, but nutritious articles of food. Pastry, cakes, candies, nuts, hot 
bread, sweetmeats, and all such rich, but not really substantial diet, 
should be forbidden to as great an extent as possible. 

Of the tonics to be given, the best are the preparations of iron and 
cod-liver oil. Of the former, we prefer commonly the syrup of the iodide 
of iron, from three to five drops, at four or five years of age, three times 
a day, in half a teaspoonful or a teaspoonful of sarsaparilla syrup. Or 
the Pulv. Ferri of the Pharmacopoeia ma}^ be given, either in the form of 
powder, mixed with dry sugar, in pill, or in the shape of the chocolate 
lozenge. From half a grain to a grain, three times a day, is the proper 
dose from three or four 3-ears to six or seven. The carbonate of iron may 
be given, if it is preferred, for any cause. Either of these preparations 
of iron, or an}' other that may be chosen, should be combined with a 
grain of quinine three times a day, whenever the appetite is poor, and 
when the digestive process seems to be slow and feeble. Or the child 
may be made to take half a teaspoonful of the fluid extract of cinchona, 
mixed with an equal quantity of syrup of ginger, half an hour before the 
meals, while the iron is given alone soon after the meals. When the at- 
tack is particularly obstinate, and when, also, it occurs in a subject who 
either inherits or exhibits signs of the tubercular or scrofulous diathesis, 
or of the existence of constitutional s} r philis, the best remedy is cod-liver 
oil, which should be given in doses of from half a teaspoonful to a tea- 
spoonful two hours after each meal. 

The local treatment must consist in the use of means intended to keep 
the passages clean and free from scabs and incrustations, and in the em- 
ployment of astringent and alterative applications. When the patient 
will submit, the nasal passages should be cleansed by means of a syringe 
once or twice a day, with tepid water, or milk and water, or with a weak 
solution of alum in water. The latter may be made in the proportion of 
from two to four grains to the ounce. If the discharges are offensive, the 
lotion used for injection should consist of the solution of chlorinated 
soda, one, two, or three drachms in two ounces of water. After the use 
of the syringe, and more or less frequently through the da}', according to 
the disposition to dryness of the surfaces, these should be lubricated with 
some oleaginous application. One of the best is glycerine, or glycerine 
rubbed up with cold cream (f3i of the former to ^i of the latter) ; or sweet 
oil, or oil of sweet almonds, may be used. These applications are best 
made by means of a camel's-hair brush. 

Amongst the astringent applications, the best are weak solutions (gr. 
v to x to water f ^i) of the nitrate of silver, which should be used only 
once a day, or solutions of the sulphate or acetate of zinc with wine of 
opium. From two to five grains of either preparation, with a drachm of 



60 COEYZA. 

Trine of opium, to an ounce of water, make a proper application. This 
may be applied twice a clay. One of the best means that we know of, 
however, after the use of the alam or soda injection through the day, is 
to apply the following ointment at night: R. Ungt. Hydrarg. Xitrat., Jss; 
Ext. Belladonna?, gr. x; Axungia?, gss. — M. This has succeeded admir- 
ably well in several cases in which we have used it. It should be applied, 
after being completely softened by a gentle heat, on a camel's-hair pencil, 
care being taken to apply it thoroughly to the surface of the mucous 
membrane itself, and not merely to the outside of the hardened scabs. 

Case. — The subject of this case, a male, was born after an easy, nat- 
ural labor, and appeared strong and well, with the exception of a little 
discharge of blood from the nose soon after birth and slight coryza, the 
latter of which continued until the child was five weeks old, when it be- 
came aggravated, and the late Dr. Charles D. Meigs was requested to 
visit the infant. One of us saw it at the same time. It was small and 
puny ; the skin was harsh, dry, and wrinkled, so that the child looked 
like a little old woman. It was very weak, and had constant secretions 
from the nostrils of thick, dark-colored pus. When the discharge col- 
lected in sufficient quantity to obstruct the passages, the respiration be- 
came exceedingly difficult, as the infant seemed incapable of breathing 
through the mouth. At such moments it seemed as though the child must 
die of asphyxia. If the nostrils were cleared by any means, by syring- 
ing, b}^ the use of a brush, or ~by blowing into them in the manner al- 
ready described, the respiration would become easy and natural, until 
the discharge collected again, when the same scene recurred. During the 
paroxysms arising from the closure of the nasal passages, the child was 
entirely unable to take the breast, but after being relieved, had no diffi- 
cult}' whatever ; the mouth was either kept shut, or if open, the tongue 
was observed to be pressed spasmodically against the roof of the mouth, 
so that it was impossible for more than a very small amount of air to pass 
over it ; the respiration was labored, and accompanied by a loud snoring 
or nasal sound. There was no other marked sjmrptora, except a nearly 
constant flatulent distension of the epigastric region. On the day before 
death, the infant seemed better, appeared to have gained flesh, and looked 
more intelligent, so that the mother was greatly encouraged; but the next 
day it was seized during one of the paroxysms of suffocation, which did 
not seem to be worse than msiTij preceding ones, with copious discharges 
of bloody and frothy serum from the mouth and nose, and died in about 
three-quarters of an hour. 

At the post-mortem examination we were not allowed to examine the 
nasal passages or throat. The stomach and bowels were healthy, but 
much distended with gas. The peritoneum was healthy, but contained 
a considerable amount of clear yellowish serum. There was serous effu- 
sion in both pleural cavities, but no traces of inflammation. The lungs 
were health}', with the exception of some ecchymosed points, and general 
infiltration with sanguineous frothy serum. The trachea and bronchia 
were natural. The heart was larger than usual, but healthy in other re- 
spects. 



DISEASES OF THE LARYNX. 61 

SECTION II. 

DISEASES OF THE LARYNX. 

GENERAL REMARKS. 

There has been much confusion amongst writers on the diseases of 
children, until within a few years past, in regard to the diseases of the 
larynx, each one differing from the other in his opinions as to the nature 
of the several disorders of that organ, and of course as to their classifica- 
tion and sjmiptorus. From later and more rigid observation it has be- 
come clear, however, it appears to us, that there are but three diseases 
of the larynx which deserve to be considered as separate and distinct 
affections ; these are simple erythematous or catarrhal inflammation of 
the larynx, unattended with spasm of the glottis, or, as that symptom 
has been emphatically named, laryngismus ; simple catarrhal inflamma- 
tion of the laiynx, attended with laryngismus, and called most properly 
spasmodic simple laryngitis, or more commonly simple, false, spasmodic, 
or catarrhal croup ; and lastly, pseudo-membranous inflammation of the 
laiynx, properly named pseudo-membranous laryngitis, and more com- 
monly called true or membranous croup. There is, moreover, another dis- 
ease, of which one of the most marked symptoms is spasm of the glottis, 
or laryngismus, attended with a hoop or stridor, which is now known by 
the name of laryngismus stridulus, but which is called also Kopp's or thy- 
mic asthma, spasm of the glottis, and croup-like convulsion. This disease 
has often been confounded with the above-named spasmodic affections of 
the larynx under the common title of croup, or has been supposed to con- 
stitute a distinct disease of the larynx; whereas now it is well known that 
the laryngismus whence its name was taken, is but one of many symp- 
toms that mark the dependence of the disease upon disordered action of 
the reflex portion of the general nervous system. 

We are well aware, also, that some most competent observers describe 
a purely spasmodic affection of the larynx, under the title of spasmodic 
croup, which they believe to be entirely independent of laryngeal inflam- 
mation, and to consist in a mere momentary contraction of the sphincter 
muscle of the larynx, produced by the sympathies which that part holds 
with other parts of the body, and especially with the digestive apparatus. 
As we have never, however, in what has now become a very considerable 
experience in the diseases of children, met with a case of spasmodic croup 
unconnected with more or less evident catarrhal inflammation of the lar- 
ynx, we are not disposed to risk increasing the confusion already attend- 
ing this subject, by making additional and more minute varieties of these 
affections than those above-named. We are quite willing to acknowledge 
that, in some cases of simple spasmodic croup, the amount of catarrhal 
inflammation of the larynx is slight, and that the symptoms of digestive 
disorder are very strongly marked, but in not a single instance of croup 
that has come under our notice, have we ever had reason to suppose that 



62 SIMPLE LARYNGITIS WITHOUT SPASM. 

the croupal sjmrptonis were dependent solely on simple spasm of the glot- 
tis (caused by some distant irritation), unattended with inflammation of 
the laiyngeal mucous membrane. In all such cases that we have met 
with, it has seemed to us that the condition of gastric, intestinal, or bil- 
ious disorders, might be explained in one of two wa}~s. Either the dis- 
order of the digestive function has rendered the child unusually suscepti- 
ble to cold, by having diminished its power of resistance to the weather ; 
or, the derangement of the bodily functions caused by the cold has weak- 
ened, amongst others, the digestive s3 T stem, and thus brought about vari- 
ous s} T mptoms of gastric or intestinal disturbance, or more commonly of 
indigestion. 



AKTICLE I. 

SIMPLE LARYNGITIS WITHOUT SPASM. 

Definition ; Frequency. — This disease consists of simple erythema- 
tous or catarrhal inflammation of the mucous membrane of the larynx, 
unattended with spasmodic closure of the organ. It is sometimes at- 
tended with ulceration, but is unaccompanied b} T exudation of false mem- 
brane. The frequency of the disease, during infancy and childhood, is 
very considerable, so much so, that not a winter passes without our meet- 
ing with a good maiw well-marked cases. 

Predisposing Causes. — The disease occurs at all periods of childhood, 
but seems to be more frequent under than over five years of age. Of 
sixty-two well-marked primary cases that we have met with in which the 
age was noted, fifty occurred in children under, and only twelve in those 
over that age. Of the former class, twelve were under one 3-ear, seven- 
teen between one and two, nine between two and three, five between three 
and four, and five between four and five. Of sixty-four cases in which 
the sex was noted, thirty-six occurred in boj^s, and twenty-eight in girls. 
As to the influence of the seasons, it may be stated that it is by far the 
most common in the fall, winter, and spring months. 

The only exciting causes of the disease which appear to have been as- 
certained with any certainty, are the action of cold, the positive influence 
of which cannot be questioned ; the inspiration of irritating substances, 
such as gases, smoke, powders floating in the air, &c. ; and violent efforts 
of crying. MM. Rilliet and Barthez state that they have twice known 
erythematous and ulcerative laryngitis to follow long-continued and vio- 
lent crying ; and M. Billard also cites this as a cause. We are acquainted 
with one case in which a slight attack of the disease appeared to have 
been brought on solely by loud and obstinate screaming. 

The disease is very apt to occur in the course of other maladies, and 
particularly of measles, small-pox, scarlet fever, bronchitis, and pneu- 
monia. 

Anatomical Lesions. — The anatomical alterations may consist of sim- 



SIMPLE LARYNGITIS WITHOUT SPASM. 63 

pie inflammation of the mucous membrane, with its various effects, or of 
the same changes in connection with ulceration. The latter class of 
lesions is almost always confined to secondary cases. In the former class, 
the mucous membrane varies in color between a deep rose and violet-red, 
which may be either uniform or only in patches. In severer cases, the 
tissue is at the same time softened or roughened, and sometimes thick- 
ened. "When redness, softening, and thickening are present, the disease 
is generally confined to certain parts, and commonly to the epiglottis and 
internal portions of the vocal cords ; but when redness alone exists, it 
usually affects the whole of the larynx, and sometimes extends to the 
trachea. In cases attended with ulcerations, these alterations exist in 
connection with those already described. The ulcerations are generally 
small, few in number, very superficial, linear in shape, and are almost 
always found upon the vocal cords. They are so slight often as to escape 
observation, unless a very careful examination be made; and. this, per- 
haps, explains the circumstance of so few persons having met with them 
in the simple acute disease. 

Symptoms; Course; Duration. — The attack generally begins with an 
alteration of the voice or cry. In infants the change in the cry alone 
exists, so that to detect the disease, it is necessary to hear the child cry. 
In older children the same alteration of the cry is present, but there is 
in addition a change of the voice, consisting of various degrees of hoarse- 
ness. These symptoms may be so slight as to be observed in the cry 
only when it is strong and forcible, and in the voice so as to strike only 
the ear of one accustomed to be with the child ; or they may be so marked 
as to be heard in the faintest cry that is uttered, and to be evident in the 
voice in a moment to the most careless observer ; or there may be com- 
plete aphonia. The} r are often intermittent in this form, and are gener- 
ally most marked in the after part of the day and during the night. 
Simultaneously with this symptom, or very soon after, cough occurs. 
This is generally hoarse and rough, and early in the attack, dry ; at a 
later period it usually becomes loose, and as this change occurs loses its 
character of hoarseness. The frequency of the cough is variable, but 
usually moderate ; as a general rule it is most frequent in the evening, 
and early in the morning, particularly in infants and young children. 
The disease is almost always preceded and attended with some coryza, 
which, in the early stage, is marked by sneezing and slight incrustations 
about the nostrils, and at a later period, by mucous and sero-mucous dis- 
charges. The respiration remains natural, except that it is sometimes 
nasal, and sometimes a little accelerated. There is rarely airr fever, or 
it is slight, and occurs only at night. There is no pain in the larynx. In 
some cases, the hoarseness of the cry, voice, or cough scarcely exists, oi- 
ls but slightly marked, and the only symptom is a diy, hard, teasing, and 
paroxysmal cough, which, from its sound, evidently proceeds from the 
larynx, and resembles very much that produced by the tickling of a foreign 
body in the throat. 

The symptoms of this disease, instead of being of the mild character 
just described, may be much more severe. The cough is more frequent, 



64 SIMPLE LARYNGITIS WITHOUT SPASM. 

hoarse, troublesome, and painful, from the scraping and tearing sensa- 
tions it occasions in the larynx. The voice is more affected, becoming 
from husky more and more hoarse, though it is very unusual for it to be- 
come weak and whispering, as in membranous and severe spasmodic 
croup. The respiration is decidedly accelerated, giving rise to slight 
dyspnoea, and there is more or less fever, which is most marked usually 
in the after part of the day and in the night. The pulse is more frequent 
than in health, rising to 120 or 130 in the minute; the skin is hot and 
dry ; the child is thirsty, restless, and uncomfortable. After a few clays 
usually, the cough becomes loose and eas}-, and ceases to be painful ; the 
voice loses its hoarse tone gradually, the fever disappears, the appetite 
and ga}-et3 T return, and the child regains its usual health. 

When the laryngeal inflammation becomes violent in this disorder, so 
as to be attended with considerable swelling of the mucous membrane, 
the case alwaj's, according to our experience, assumes the shape of grave 
spasmodic laryngitis. To our article upon this latter affection, spasmodic 
croup, we must refer the reader for further information on this point. 

In nearly all the cases of this form of laryngitis that have come under 
our observation, we have found, upon examining the fauces, more or less 
decided inflammation of the tonsils, soft palate, and pharynx. In cases 
following a rather chronic course, from two to four or six weeks, which 
are rarely accompanied by fever or hoarseness, except at the invasion, 
and sometimes in the evening, the pharyngeal mucous membrane pre- 
sented a roughened, thickened appearance, and the tonsils and uvula 
were more or less enlarged and tumefied. 

There is a form of obstinate, troublesome cough, to which children are 
subject, and of which we have met with a good many examples, that must 
be noticed here. It depends evidently upon chronic inflammation, with 
thickening of the mucous membrane lining the upper portion of the larynx. 
Of this we feel assured, not from an} T post-mortem examination, since we 
have never known a child to die of, or while laboring under the affection, 
but from the tone and character of the cough, from its occasional asso- 
ciation with hoarseness of the voice, from its being almost invariably co- 
incident with thickening and granulation of the pharyngeal mucous mem- 
brane, and from the fact that the most careful physical examination of 
the chest fails to reveal airy disease whatever of the lungs. The cough 
is harsh, rough, and, so to speak, tearing in its character. It often 
sounds, especially towards evening and in the early part of the night, 
croupal in its tone. It is usually very frequent, not so much, however, 
during the day, as in the evening and night. It is very generally in- 
creased by the horizontal position, so that when the child is put to bed, 
he will begin to cough violently and almost incessantly, and will continue 
to do so for one, two, and even three or four hours. The cough is so 
constant and so severe as to cause the greatest disturbance not only to 
the patient, who will toss and turn in bed in the most restless manner, 
but to the mother or attendants, who are excessively anno3^ed, and some- 
times alarmed, by its constancy and obstinacy. Children who become 
subject to this species of cough, often have repeated attacks during the 



DIAGNOSIS. 65 

cold seasons of the year, the slightest exposure sometimes bringing them 
on. Each attack may last from a few days to several weeks. In one case 
we knew it to last, without once entirely ceasing, three months, and in 
another it lasted, with imperfect suspensions of a few days, during the 
same length of time. Both these cases occurred in hearty boys, one in 
the second, and the other in the third year of life, and yet both were 
vigorous and health}* children, as time has shown. In many other in- 
stances, we have known it last two, three, and four weeks, proving all 
that time most troublesome and rebellious to treatment. During the day, 
the child generally seems perfectly well, or at most merely a little pale 
and languid, and he coughs but moderately, but as soon as night comes 
on, and especially when he is put to bed, the cough begins, and goes on 
for hours, as stated above, unless some remedy, and particularly some 
opiate, be given to check it. It is most annoying to the practitioner, for 
he finds that his usual remedies act merely as palliatives. They check 
and modify, perhaps overcome it for a time, but the next change in the 
weather, and especially the least exposure to cold and damp, start it 
afresh, and he has to resort again to the same round of treatment to sub- 
due it. To the members of the family also' it gives great anxiety. At 
first, they fear it must run into croup, which, however, it very seldom 
does, and then, finding how difficult it is of cure, and how often it recurs, 
the}* can scarcely be persuaded that it does not depend on some serious 
disease of the lungs. 

The principal cause of this form of chronic laryngeal irritation is, so 
far as we have been able to ascertain, an unusual susceptibility of the 
laryngeal mucous membrane, sometimes the result of a congenital idio- 
syncrasy, and at other times the result of influences coming into action 
after birth, and especially of improper dress. We have generally met 
with it in children dressed upon the hardening system so much in vogue 
with man}* of our most highly educated citizens. The low frock, leaving 
the neck and upper half of the chest exposed to the air, the bare arms 
and bare legs, persevered in through our cold autumns, winters, and 
springs, have certainly, in most of our cases, been the cause of this 
troublesome and chronic cough. 

Our experience since the publication of the last edition full}* confirms 
the truth of these remarks upon the style of clothing just referred to. 
We certainly do not see so many cases of obstinate laryngeal cough as 
we formerly did, for the simple reason that but few of the families we 
take care of, adhere to the old-fashioned system of leaving their children 
half naked. 

The duration of the disease varies according to its form and the cir- 
cumstances under which it occurs. When primary, it lasts usually from 
a few days to one or two weeks, but when it becomes chronic, as we have 
known to happen in a good many instances, it has lasted from two to four 
or six weeks, and even two and three months. The duration of secondary 
cases depends, of course, upon that of the disease during which they occur. 

Diagnosis. — The diagnosis of simple laryngitis is very easy. The 
hoarseness of the cry, voice, and cough, the redness of the mucous nioni- 

5 



66 SIMPLE LARYNGITIS WITHOUT SPASM. 

brane of the pharynx, and the absence of general symptoms, will distin- 
guish it from any other affection. In somewhat severer cases of this form, 
in which the cough is more frequent and harassing, the general symp- 
toms more strongly marked, and the respiration somewhat hurried and 
oppressed, the attack may at first view present the appearances of bron- 
chitis or pneumonia. The absence of the plrysical signs of these affec- 
tions will show at once, by negative evidence, the true nature of the case. 

In some cases in which there is little or no hoarseness of the voice 
or cough, the symptoms strongly resemble the early stage of hooping- 
cough. We have met with five instances in which it was difficult not to 
believe, for two aud three weeks, that the attack was really one of that 
disease. In one of these the resemblance was so close, that for several 
days there was a distinct hoop during the fit of coughing, with vomit- 
ing at the close of the paroxysm. The grounds for deciding that the case 
alluded to was not one of pertussis, were, that the attacks came on like 
laryngitis, after measles, and that the paroxysms occurred only at night. 
In the other cases a correct diagnosis was arrived at only by attention to 
the state of the fauces, which are almost always more or less inflamed and 
thickened in laryngitis, whilst they are not so in pertussis, and by watch- 
ing the progress of the sickness. 

Prognosis. — The prognosis is always favorable in the mild form of the 
disease. We have never met with a fatal case. 

Treatment. — The treatment of the milder cases of this form of laryn- 
gitis ought to be very simple. Children under four or five years old ought 
to be confined for the first few days to the house, unless the weather be 
dry and not intensely cold. In mild weather they may be sent out for a 
short time in the middle of the day. When the patient is five or over, he 
may continue to go out through the day, unless the weather be very bad. 
Much must depend upon the peculiarities of the child's own constitution. 
These can only be learned b} T observation on the part of the mother. 
Some children bear going out with such attacks perfectly well; others, if 
sent out with this simple laryngitis, are almost certain to have spasmodic 
croup or bronchitis more or less severely. When there is any febrile 
movement in the case, no matter how slight, the child ought to be kept 
quiet, and confined to the house. Attention to this point, therefore, care- 
ful management of the clothing, slight reduction of the diet if there be 
any fever, a foot-bath at night of simple water, or of water containing a 
little mustard, the application of some slightly stimulating liniment to 
the front of the neck and throat twice a day, and the occasional internal 
administration of some gentle expectorant and anodyne close, constitute 
all that is necessary in the great majority of cases of this kind. The best 
internal remedies are a few drops of syrup of ipecacuanha, with pare- 
goric, laudanum, or solution of morphia, given every evening as the child 
is put to bed, or occasionally through the day also, if the cough is trouble- 
some. A combination of syrup of seneka with that of ipecacuanha, will 
often be found very serviceable. 

The treatment of the chronic laryngeal cough, unattended by fever or 
any severe constitutional symptoms, described above, requires some spe- 



TREATMENT. 67 

rial remarks. In the first place, we have to state that we have seldom 
succeeded in curing it until we had obtained from the parents their con- 
sent (often obtained with great difficulty) to a proper dress for the child. 
Expectorants, nauseants, opiates, antispasmodics, counter-irritants, and 
local applications, have nearly always failed to procure more than tem- 
porary alleviation, until the child has been dressed warmly. We have 
cured, on several occasions, this kind of cough, after many ineffectual 
trials with the above remedies, only hy insisting upon a mode of dress 
which covers the neck, arms, and lower extremities. A merino or soft 
flannel shirt, with long sleeves and high neck, long merino stockings, and 
thick muslin or canton-flannel drawers, have done more in such cases to 
effect a cure than all other means. This style of dress has removed the 
cause, the constant chilling of the body, and then the usual therapeutic 
measures will, no doubt, assist in overcoming the local changes which 
constitute the disease. 

The best therapeutic measures to be adopted in such cases are the ap- 
plication, once a day, of a solution of nitrate of silver, of from five to 
twenty grains to the ounce, low down into the pharynx and chink of the 
glottis, by means of a small sponge-mop on a bent whalebone. After sev- 
eral applications have been made daily, they should be made only once in 
two or three da}~s. The strength of the solution is to be determined by 
the condition of the pharyngeal mucous membrane, as we may assume this 
to mark, in some measure, the state of the contiguous tissue of the glottis. 
"When the mucous membrane of the fauces is covered with large, protu- 
berant follicles, when the tissue between the follicles is thickened, re- 
laxed, spongy-looking, and when the color of the membrane is dark 
red, the stronger solutions are the best ; when, on the contrary, the mu- 
cous membrane is not roughened nor thickened materially, when the fol- 
licles are small, when the color of the tissues is bright red, it is best to 
use only the five-grain, or even a weaker, solution. The most useful in- 
ternal treatment in our hands has been the exhibition, three times a day, 
of one of the following mixtures, preferring that with antimony for a 
vigorous child, and that without antimony for one less robust. 

]&. — Potass. Carbonat, .... 

Yin. Antimon., 

Tinct. Opii, 

Syrup. Simp., 

Aq. Cinnamom., ..... 
Ft. Mistura. 



R. — Potass. Carbonat., .... 

Tinct. Opii, 

Syrup. Senegse, 

Syrup. Tolutani, 

Aq. Pluvial, 

Ft. Mistura. 

One of the most troublesome cases of cough we ever met with, occurred 
two years since in a fine, intelligent, but not robust bo}', four years old. 



Bi- 






fgss 


vel i 




gtt. 


xxiv, 


vel xlviii 


f^- 






fgii. 


— M. 




Bi- 






gtt. 


xxiv, 


vel xlviii. 


fgii. 






f 3 vi 






fgii. 


— M. 





68 SPASMODIC SIMPLE LARYNGITIS. 

He was seized with a hard, obstinate cough, which, in a few days, became 
really terrible from its almost incessant repetition for many hours at a 
time. The cough was dry, tickling, choking, repeated with nearly every 
breath, and so incessant as to drive the parents — and we may add the 
doctor— almost frantic. The little fellow at last found out, instinctively, 
that, by placing himself on the front of the body on two pillows, with the 
chin hanging over the edge of the upper one, he coughed less frequently, 
and with less violence, than in any other position. Discovering that the 
uvula was very much lengthened from relaxation and elongation of its 
mucous membrane, we touched the lower sharp extremity with the lunar 
caustic stick twice a day. At the same time the following mixture, which 
we had often used to control general nervous irritability in children, was 
prescribed; and this, with the lunar caustic application, finally controlled 
the cough. It was as follows : 

R. — Vin. Antimonii, ........ gtt. xlviij. 

Ext. Valerianae Fl., 

Tr. Opii Camph., aa ...... f 31J. 

Syrup. Simp., f ^ss. 

Aqua, f£j.-M. 

S. A teaspoonful every hour or two when the fits of coughing set in. 

After a few da} T s, when the irritability of the fauces was somewhat sub- 
dued, the elongated portion of the mucous membrane of the uvula was cut 
off close to the muscle, and there was no renewal of the cough afterwards. 

When the cough is very harassing at night, from two to four drops of 
laudanum, with from ten to twenty drops of S3 7 rup of ipecacuanha, or two 
grains of Dover's powder, given once or twice in the evening, have an- 
swered better than any other means. When the patient presents an anem- 
ical appearance, or other symptoms marking a general deterioration of 
the health, iron, and especially the syrup of the iodide of iron, given 
three times a day, has assisted in removing the cough, and especially in 
lessening the extreme susceptibilhry of the system to changes of the wea- 
ther. The diet ought to be light, but strengthening. Good fresh meat, 
with simple nutritious vegetables for dinner, and bread and milk morn- 
ing and evening, constitute the most proper diet. In bad weather, during 
the cold seasons of the year, the child should be confined to the house. 



AKTICLE II. 

SPASMODIC SIMPLE LARYNGITIS, OR SPASMODIC OR FALSE CROUP. 

Definition; Synonymes; Frequency; Forms. — Spasmodic laryngitis 
is a disease of the larynx almost peculiar to children, consisting of 
simple catarrhal inflammation, without pseudo-membranous exudation, 
of the mucous membrane of that organ, attended with spasmodic con- 
traction of the glottis, or laryngismus, occasioning violent attacks of 
threatened suffocation. 



PREDISPOSING CAUSES. 69 

It is the disease commonly called in this country croup, or, by those 
who make the distinction between it and pseudo-membranous laryngitis 
or true croup, spasmodic croup. It is known also by the names of false 
or pseudo-croup. We prefer the term spasmodic laryngitis, because it is 
expressive of the essential characters of the disease. It is the stridulous 
laryngitis of MM. Guersent and Yalleix; the stridulous angina of M. 
Bretonneau ; the acute asthma of infanc} T of Millar ; and the spasmodic 
croup of Wichruann, Michaelis, and Double. It is not the laiyngismus 
stridulus described by the English authors, Kerr, Ley, and Marsh, which 
is the same as the thymic or Kopp's asthma of the Germans, and spasm 
of the glottis of the French. It is called by Dr. Wood, in his work on 
the practice of medicine, catarrhal croup. 

Spasmodic laryngitis is one of the most frequent of the diseases which 
occur during childhood in this country. It is so common in this city, 
that almost all mothers who have had any experience in sickness, keep 
some remedy for it in their houses, which they are in the habit of resort- 
ing to upon their own judgment. 

During the last 20 3 T ears we have had under our charge 109 cases of 
the disease, of which we have kept an accurate record, and at least 100 
other cases, of which we have no written account. Of the 109 cases, 86 
were of the mild, and 23 of the severe form. 

We shall describe two forms or degrees of this disease, the mild and 
the severe. Without this distinction it would be impossible to give an 
accurate account of the disorder, since the two forms differ so much in 
aspect as to render them almost as much unlike as though they were two 
distinct affections. Moreover, the mild form differs so widely from mem- 
branous or true croup in its course and symptomatology, that the distinc- 
tion between the two is readily made out, whilst the severe form, on the 
contraiy, resembles true croup so much as to demand often veiy nice 
powers of observation to distinguish them, and yet the distinction is one 
of vast consequence to the patient, since the prognosis and treatment are 
widely different in the two diseases. 

Predisposing Causes. — The disease is much more common at some- 
ages than others. It occurs most frequently during the period of the 
first dentition, being more common in the second year of life, which is 
the time of greatest activity of the first dentition, than at any other age,, 
though it is often met with also in the third and fourth years. In the 
fifth year it still occurs occasionally, in the sixth and seventh it becomes 
rare, and after the seventh we have seen it but a few times. Of 106 cases 
of the disease that we have attended, in which the age was noted, 8 
occurred in the first year of life, 33 in the second, 22 in the third, 26 in 
the fourth, 12 in the fifth, 2 in the sixth, 2 in the seventh, and 1 in the 
eighth. 

It is said to be more frequent in boys than girls, and this seems borne 
out by our own experience, since of 106 cases, 62 occurred in boys, and 
44 in girls. 

Spasmodic croup occurs usually as a sporadic disease, but is said by 
some authors to prevail at times as an epidemic. We have never had any 



70 SPASMODIC SIMPLE LARYNGITIS. 

reason to suppose that it was strictly an epidemic like membranous croup, 
which appears to a considerable extent in some years, and in others is 
scarcely seen. We believe rather that the unusual prevalence of spas- 
modic laryngitis at certain periods, in comparison with others, depends 
on the fact that certain states of the weather or season predispose or 
excite to it in a greater degree than usual, and thus occasion a large 
number of children to be attacked with it. 

It is generally believed to be hereditary in certain families, and of this 
we ourselves have no doubt. We are acquainted with one family in this 
city, in which the children for three generations were extremely liable to 
it ; with another, in which the grandmother and grandchildren were fre- 
quently attacked; and with a third, in which the father and children 
showed the same predisposition in the most marked manner. The idea 
is, moreover, entertained by many people in this coruru unity. 

The natural constitution of the child does not seem to have much 
influence upon the liabilnVy to the disease ; it occurs indifferently in the 
weak and strong. We have no doubt, however, that there are certain 
transient conditions of the health which do affect the liability to it, since 
it has long been remarked that disturbances of the digestive functions 
frequently invite it, and since we have often ourselves found it most apt 
to attack those who are liable to it, when they happen to be laboring 
under bilious disorders or indigestions. It is most common during cold 
weather. 

Exciting Causes ; Cold. — By far the most frequent exciting cause is 
the action of cold ; either the passage from a warm into a cold atmosphere, 
or prolonged exposure to cold and damp. It has been known on several 
occasions to follow long-continued ciying, doubtless from inflammatory 
action set up in the lanmx, as a consequence of the excessive determina- 
tion of blood to that part during the act of ciying. We were assured, 
some time since, by a very intelligent woman, that her little daughter 
had. at the age of two years, a well-marked attack of croup, after a severe 
and long-continued fit of ciying from some contrariety. 

Anatomical Lesions. — Mild cases of spasmodic laryngitis are so rarely 
fatal, as to leave us in some doubt as to the character of the anatomical 
lesions, or whether there are indeed any perceptible alterations of the 
tissues. We have never ourselves met with a fatal case of this form, and 
are therefore unable to give any personal account of the condition of the 
larynx, though we have never doubted, from the nature of the symptoms, 
the hoarseness, the dry cough, which afterwards becomes loose, and the 
whole aspect of the disease, that the anatomical condition of the affected 
organ must be one of slight inflammatory lryperaBinia. In some cases, 
however, that have been examined, a little mucus in the larynx, and slight 
redness have been found, while in others no change has been detected. 
Dr. Wood ( Treat, on the Prac. of Med., vol. i, p. 779) accounts for this ab- 
sence of morbid appearances in the following plausible manner : " In some 
rare instances, no signs of disease are discovered in the mucous mem- 
brane, and the patient has probably died of spasm, consequent upon high 
vascular irritation or congestion, the marks of which disappear with life." 



SYMPTOMS. 71 

Cases of severe spasmodic croup have not unfrequently proved fatal, 
and the anatomical alterations of this form of the disease have therefore 
been well ascertained. These alterations consist of either simple catarrhal 
inflammation of the laryngeal mucous membrane, or of inflammation at- 
tended with ulceration. When the inflammation is simple, the membrane 
is changed in color, either uniformly or in spots, to a deep rose or dark 
red tint. This may be the only alteration, or the tissues may be found 
also softened, or roughened and thickened. When the redness, thicken- 
ing, and softening, are all present, these appearances are usually confined 
to certain parts, and particularly to the epiglottis and vocal cords, but 
when redness alone is present, it generally affects the whole of the larynx, 
and ma}' extend to the trachea. To the alterations just described are 
sometimes added, as was stated above, ulcerations. These are commonly 
small, few in number, of a linear shape, and are usually seated upon the 
vocal cords. The}' are so slight as to escape observation, unless carefully 
looked for. 

Symptoms ; Duration. — The invasion of the mild form of spasmodic 
croup is generally very sudden, for though it is often, probably in a large 
majority of cases, preceded for a few hours or a day or two by slight 
coiyza, hoarseness, and cough, these S3 T mptoms are seldom noticed at the 
time, and the child is not supposed to be sick until seized with the parox- 
ysm of suffocation, which is pathognomonic of the disease. This occurs 
in much the larger number of cases during the night, and very generally 
wakes the child from sleep. Of sixty-four cases observed by ourselves, in 
which the time of the attack was noted, it occurred in the night in sixty- 
two, whilst in two it came on in the afternoon. The period of the night 
at which it takes place is very irregular, but it is much more apt to be 
before than after midnight, as is shown by the fact, that of forty-two 
cases in which this circumstance was ascertained, the attack was before 
midnight in thirty, and after in twelve. This agrees very closely with 
the statement of MM. Rilliet and Barthez, that it has been observed most 
frequently at eleven in the evening. The duration of the paroxysms 
varies considerably, and depends a good deal upon the treatment em- 
ployed. They may last from a few minutes to several hours, but are 
seldom shorter than from half an hour to an hour. The number of the 
attacks also varies. In some cases there is but one, though very gener- 
ally there are several. When the attack occurs early in the night, it is 
very apt to recur again towards morning, and, unless means of prevention 
are used, on the following night also, and even, though this happens much 
more rarely, on the third night. As a general rule, the first attack is the 
most severe. 

When the paroxysm comes on, the child is wakened from sleep by the 
sudden occurrence of sj'mptoms apparently of the most alarming and 
dangerous character. These consist of loud, sonorous, and barking 
cough; of prolonged and labored inspiration, accompanied by a shrill and 
piercing sound, to which the term stridulous is applied; of rapid and irreg- 
ular respiration, amounting often to violent dyspnoea, or seemingly im- 
pending suffocation : the child, alarmed and terrified at its condition, and 



72 SPASMODIC SIMPLE LARYNGITIS. 

at the fright of those around, its countenance expressive of the utmost 
anxiety, cries violently between the attacks of coughing, and begs to be 
taken on the lap, or sits up or tosses itself upon the bed, struggling ap- 
parently with the disease, which seems for the moment to threaten its very 
existence. The voice and cry are hoarse, and sometimes almost extin- 
guished during the height of the paroxysms, but become distinctly audi- 
ble, and often nearly natural, in the intervals between them ; differing in 
this respect from pseudo-membranous croup, in which they remain per- 
manently hoarse or whispering. TVe have never heard, in this disease, 
the whispering voice and the short smothered cough of true croup. The 
face, head, and neck, are at first deeply flushed, and as the paroxysm be- 
comes more violent, assume a dark livid tint, which afterwards passes 
into a deadly paleness, if the attack be long continued. These changes 
in the coloration depend upon the arrest of the respiratory function and 
a consequent partial asphyxia. The pulse is frequent during the par- 
oxysm, and the skin sometimes heated. After a longer or shorter period, 
generally from half an hour to an hour, the respiration becomes more 
tranquil ; the stridulous sound disappears entirety, unless the child be dis- 
turbed and made to ciy, when it again becomes distinct ; the cough is less 
frequent and less boisterous, and the child generally falls asleep. The 
attack is very apt to recur towards morning, as has been stated, and if 
not then, the following night. The patient often seems perfectly well the 
da}^ after the first paroxysm, with the exception, perhaps, of slight cough. 
This is no reason, however, for supposing that the disease will not return 
in the course of the second night, which is almost sure to happen, unless 
measures be taken to prevent it. The cough generally continues for a 
day or two, but soon loses the peculiar character expressed by the term 
croupal ; it becomes less frequent and more loose, and the child is com- 
monly well again in two or three days. Sometimes, however, the cough 
lasts for several days, becoming gradually less frequent, until at last it 
ceases entirety. 

There is very little fever in mild cases, for though the pulse is accele- 
rated and the skin warm during the paroxysm, these symptoms disappear 
very soon after that is over. In more severe cases, on the contrary, there 
may be considerable fever, the pulse becoming frequent and full, and the 
skin hot. The febrile movement is most apt to occur after the first par- 
oxysm, as a consequence, apparently, of the slight catarrh which remains 
after the attack. 

In the few fatal cases on record, the paroxysms have generally become 
more frequent and more violent by degrees, and death has occurred from 
suffocation. In other instances, death has been the result of prostration, 
which itself has probably depended on imperfect hematosis. 

Recurrences of the disease are very common, children sometimes having 
several attacks in a single winter. This is not the case in true croup. 
We have known but two children to have a second attack of that disease. 

The severe form of spasmodic laryngitis may begin as such or result 
from an aggravation of the mild form ; or the case may commence as one 
of simple laryngitis without spasm of the glottis, and as the intensity and 



SYMPTOMS. 73 

extent of the laryngeal inflammation increase, it may assume all the fea- 
tures of the form under consideration. "Whatever be the mode of onset 
of the case, this form of the disease sets in with hoarse, frequent cough, 
difficult respiration, restlessness, and more or less violent fever, symp- 
toms which almost always become severe for the first time at night, and 
usually between early evening and midnight ; though, in some few cases, 
they make their first appearance during daylight, and this is very much 
more apt to happen in this than in the mild form of spasmodic croup. 
During the night the symptoms increase in severity ; the respiration is 
frequent and difficult, and, after a time, attended with the striclulous 
sound in inspiration and expiration caused by narrowing of the glottis : 
the cough is hoarse, dry, and cronpal, and unattended with expectora- 
tion ; the voice becomes hoarse, and fever sets in, the pulse becoming 
full and frequent, the skin hot and dry, and the face flushed. These 
symptoms persist, with greater or less severity, throughout the night, 
while from time to time, the} T increase to such an extent as to seem to 
threaten suffocation, resembling then exactly the paroxysms described as 
occurring in the mild form of the disease. They usually subside, how- 
ever, very decidedly towards morning, the breathing becoming easier, the 
striclulous sound less loud, or ceasing altogether, the fever diminishing, 
and the patient becoming in all respects much more comfortable. This 
amelioration of the child's condition often continues until the after part 
of the day or till evening, when the same train of symptoms reappears. 
In other cases the disease scarcely subsides at all for two, three, or four 
days, but continues throughout the day and night to exhibit the same 
symptoms as have been described above. In cases of this kind, which 
are not rare, the disease assumes many of the alarming and dangerous 
characters of pseudo-membranous laryngitis or true croup, and it becomes 
very difficult often to distinguish between the two. If no favorable change 
take place, the dyspnoea becomes so violent as to threaten suffocation ; 
the cough is rare and short ; the voice is reduced to a mere whisper; the 
pulse becomes small, extremely rapid and thready ; the countenance, at 
first livid and congested, assumes a pale, cadaveric appearance ; the fea- 
tures are contracted ; the child becomes comatose or delirious, and death 
occurs from slow asphyxia, or sometimes in an attack of general convul- 
sions. 

In favorable cases, on the contrary, the dyspnoea, and especially the 
stridulous sound, diminish ; the cough becomes loose, less hoarse, and 
loses its croupal character ; expectoration of mucous sputa takes place in 
older children, whilst in younger, the loose gurgling sound produced by 
the discharge of the sputa into the fauces, is heard at the termination of 
each cough; the voice becomes clearer and stronger; the fever diminishes ; 
the child regains its spirits and disposition to be amused ; and soon all 
dangerous symptoms have disappeared, and the recovery is established. 

In nearly all the cases that have come under our observation, we have 
found, upon examining the fauces, more or less decided inflammation of 
the tonsils, soft palate, and pharynx. 

The duration of the severe form of spasmodic croup depends on the 



74 SPASMODIC SIMPLE LARYNGITIS. 

violence of the attack, and on the mode of treatment. When the treat 
nient is begun with from an early period, the disease is much sooner 
overcome than when allowed to run on for some time without remedies. 
In cases of moderate severity, the violence of the symptoms usually sub- 
sides after thirty-six or fort} T -eight hours. In more violent cases, on the 
contrary, the symptoms seldom subside definitively before the third, 
fourth, and not unfrequently the fifth day. In no case that has come 
under our observation, has the disease continued to present dangerous 
s}*mptoms after the fifth day, unless, as not unfrequently happens, the 
inflammation spreads to the bronchia or tissue of the lungs, producing 
bronchitis or pneumonia. But even after the signs of severe laryngeal 
inflammation have disappeared, there almost always remains for several 
da}'s longer, some cough and huskiness of the voice, marking that the 
mucous membrane of the larynx has not yet regained completely its 
health}' condition. The disease is said to have proved fatal in twenty- 
four hours. 

Xature of the Disease. — Authors hold very different opinions as to 
the nature of spasmodic laryngitis. By Underwood, Dewees, and Eberle, 
it is confounded with membranous laryngitis, the} T making no distinction 
between false or catarrhal, and true or membranous croup. Dr. Cheyne 
{Cyclop. Pract. Med., Art. Croup), treats of the two affections as one and 
the same disease, differing only in their degree of violence. Dr. Copland 
(Diet, of Pract. Med., Art. Croup), describes spasmodic croup as a variety 
or modification of true or membranous croup. He supposes that the 
modifications of true croup are attributable to "the particular part of the 
air-passages chiefly affected, to the temperament and habit of body of the 
patient, and the intensny of the causes." It seems to us, however, that 
these views as to the nature of the two diseases are not correct, and we 
are induced b}- personal observation to regard them as distinct affections, 
which may, in the great majority of cases, be distinguished from each 
other at a very early stage, b}^ a careful observer. The comparative fa- 
tality of the two diseases alone is sufficient to establish a wide difference 
between them. Thus, of 35 cases of the pseudo-membranous form that 
we have seen, 16 died; while of considerably more than 200 cases of the 
spasmodic form that we have seen, not one has been fatal. M. Guersent 
states that of ten cases of the former disease, scarcely two escape ; while 
of upwards of a hundred of the latter that he has seen, not a single one 
was fatal. (Diet, de Med., t. ix, p. 365.) 

The different effects of treatment in the two affections also point to a 
wide difference in their nature. True croup is almost inevitably fatal, 
unless attacked at an early period by energetic remedies, while the 
mild spasmodic form seldom resists the exhibition of an emetic, a warm 
bath, or of nauseating doses of ipecacuanha or antimonj^, and. the severe 
form, though of a most threatening appearance, almost always yields 
to the proper employment of very moderate local depletion, aided by 
the use of expectorants, emetics, opiates, and correct hygienic means. 
When we add to these circumstances, the differences in the anatomical 
alterations in the two diseases, the difference in the mode of invasion, in 



DIAGNOSIS. 75 

the cough, voice, cry, fever, duration of the attack, and state of the con- 
stitution, all of which will "be carefully described in the remarks on diag- 
nosis, we do not see how we can resist the conclusion that they are two 
distinct disorders, and not, as was formerly generally asserted by Eng- 
lish writers, degrees or modifications of the same. 

TVe believe, therefore, that mild spasmodic laryngitis is a disease con- 
sisting in slight catarrhal inflammation of the mucous membrane of the 
larynx, attended with violent spasmodic contraction of that organ, or, as 
that condition has been called of late, laiyngismus. The spasm of the 
laryngeal sphincter seems to be the result of a disordered action of the 
excito-inotory innervations of the part, the irritant, which is productive 
of the morbid innervation, being, in all probabiluVr, the inflammation of 
the laryngeal mucous membrane, which has been already stated to con- 
stitute one element of the malady. The nervous element predominates 
in the early part of the attack, but towards the conclusion, the spasmodic 
symptoms disappear entirety, and we have left only those which depend 
on the local tissue-changes. 

In severe cases of the disease we have the same element of laryngeal 
spasm, or laryngismus, coincident with, and produced by, a much more 
intense and dangerous inflammation of the mucous membrane of the part 
than exists in the mild form. 

Diagnosis. — Unquestionably the disease with which spasmodic laryn- 
gitis is most likely to be confounded is pseudo-membranous laryngitis, or 
true croup. There is very little difficulty, however, in distinguishing the 
mild form of spasmodic croup from true croup, whilst in regard to the 
severe form, it may be safely stated, that the distinction cannot, in some 
cases, be made with positive certainty, except by watching the course of 
the sickness. 

Mild cases of spasmodic croup may be distinguished from membranous 
croup by a comparison of the different symptoms as they arise. The 
most important of these are : the invasion, in one sudden and almost 
invariably in the evening or night, in the other, slow and creeping, the 
paroxysm first occurring indifferently day or night ; the cough, in one 
hoarse and boisterous, in the other hoarse and frequent at first, but rare 
and smothered towards the end ; the voice, in one hoarse, but never 
scarcely whispering, and if so, only during the height of the paroxysm, 
in the other hoarse at first, and soon permanently whispering or entirely 
lost ; the cry, in one hoarse and stridulous only at the moment of the 
paroxysm, in the other permanently so ; the respiration, in one stridulous 
and difficult only during the paroxysm, and in the interval perfectly 
natural, in the other, at first natural, becoming by degrees permanently 
stridulous, and attended by the most violent dyspnoea, with remarkable 
prolongation of the expiration and even with recession of the base of the 
thorax in inspiration ; the fever, in one very slight and generally observed 
only during the nocturnal paroxysm, in the other much more consider- 
able and permanent; and lastly, the duration, in one seldom more than 
two or three daj^s, in the other rarely less than six, and very often eight 
or ten days. M. Trousseau states that the hoarse-sounding croupal 



76 SPASMODIC SIMPLE LARYNGITIS. 

cough, is not a sign of the presence of exudation in the larynx, but rather 
of its absence ; but, " when the cough, croupal at first, becomes less and 
less frequent, and ends with being nearly insonorous with suffocation, 
there is true croup, that is to sa} T , with plastic exudation in the larynx." 
This is precisely our own experience. The rare, insonorous cough of M. 
Trousseau, is the condition which we have expressed by the term smoth- 
ered. 

In order to render the diagnosis still clearer, we add the following 
table, which is altered from one given by MM. Rilliet and Barthez. 

MILD SPASMODIC LARYNGITIS. PSEUDO-MEMBRANOUS LARYNGITIS. 

Begins with coryza and hoarse cough, In epidemic form, begins as pseudo- 
or more frequently with a sudden attack membranous angina. In sporadic form, 
of suffocation in the night. Fauces nat- invasion of slight hoarseness for a day or 
ural, or merely slight redness, as in sim- two. There is fever, increase of the 
pie angina. hoarseness, with hoarse, croupal cough ; 

in most of the cases, pharyngeal exuda- 
tion, and a little later, paroxysms of suf- 
focation. 
After the paroxysm, the child seems The fever continues ; stridulous respi- 
well, the fever disappears, or is very ration ; prolonged and difficult expira- 
slight. Voice natural or only slightly tion ; recession of base of thorax during 
hoarse ; not whispering. inspiration ; cough hoarse and smothered ; 

voice hoarse and whispering. 
If the paroxysm returns, it is during The dyspnoea and suffocation increase; 
the following night, and it is less severe ; the voice and cough are smothered or ex- 
the hoarseness disappears ; the cough be- tinguished ; stridulous respiration per- 
comes loose and catarrhal. sists. 

Duration seldom more than three days. Duration seldom less than five or six. 

The hoarseness continues for several 
weeks. 
Very rarely fatal. Fatal in the majority of the cases. 

The only real difficulty in the diagnosis is the distinction between the 
grave form and pseudo-membranous laryngitis or true croup unconnected 
with angina; and this, it would appear from all evidence, cannot in some 
cases be made with absolute certainty. The only certain and indubitable 
sign by which to distinguish them, is the presence of false membranes in 
the expectoration. The existence of this symptom is proof positive of 
pseudo-membranous disease, but its absence is no proof that the case 
must be one of simple inflammation ; for, even though the membrane has 
been exuded in large quantities within the larynx, it is not always thrown 
Off by the effort of coughing or vomiting. To show the difficulty of the 
diagnosis, we will cite the case quoted by M. Valleix (loc. ciL, t. i, p. 
21 1) from M. Hache, of a child supposed to be laboring under true croup, 
who was sent to the Children's Hospital in Paris, in order to have the 
operation of tracheotomy performed. The absence of false membrane in 
the expectoration, and a slight remainder of clearness of the voice, occa- 
sioned the suspension of the operation. The child died, and no pseudo- 
membrane whatever was found in the larynx. The only lesions were mod- 
erate redness of the mucous membrane, without tumefaction, and without 
narrowing of the glottis ; so that the fatal termination must be ascribed 



DIAGNOSIS. 77 

to spasmodic constriction of the glottis, or to tumefaction of that part 
which had disappeared after death. 

Nevertheless, though the diagnosis is difficult, it can almost always be 
made out with certainty by attention to the following points. The pseudo- 
membranous form of the disease is usually preceded or accompanied by 
the presence of false membranes in the fauces, which is not the case in 
spasmodic simple laryngitis ; the sj^mptoms of invasion of the former dis- 
ease are less acute than those of the latter, the fever being less violent, 
and the restlessness and irritability less marked, than is usual in the 
simple affection, in which the general symptoms are decided from the 
first. The hoarseness of the voice and cough follow a different course 
in the two diseases ; the progress of these S3 T mptoms being slow and 
gradual in the membranous, and much more rapid in the severe spas- 
modic form. The fever is marked throughout the attack in the severe 
spasmodic disease, whilst in the other form it seldom reaches a high de- 
gree of intensit}'. Lastly, the presence of portions of false membrane 
in the expectoration, in connection with the laryngeal symptoms, affords 
positive evidence of the existence of true croup. 

Of the characters just enumerated as likely to aid us in distinguishing 
between severe spasmodic and true or membranous croup, we wish to call 
the reader's attention in greater detail to two, the condition of the voice, 
and the stridulous respiration. The former is, we have no doubt, much 
the most important single symptom. In membranous croup, the voice 
begins by being hoarse, but soon becomes weak, so that after the disease 
has lasted three or four days, it changes from hoarse to whispering ; it 
becomes, in fact, suppressed. In severe spasmodic croup, the voice is 
hoarse at first, and becomes more so as the disease goes on, but it very 
rarely becomes whispering as in true croup, but almost always retains a 
good volume, so that when urged the child can speak out loudly. Xow 
this is never the case in the membranous disease, for, as the fibrinous 
exudation is deposited on the vocal cords and in the ventricles of the 
larynx, it suspends almost entirely the functions of those parts, and the 
voice is more or less completely suppressed. The remarks just made in 
regard to the voice will apply also to the cry, which should be carefully 
studied in 3 T oung infants. 

The second very important symptom is the stridor. This is, as might 
be expected, more marked in all its features in true than in false croup, 
since in the former it depends on a permanent and considerable obstacle 
to the passage of the air through the larynx. That tube is, in fact, com- 
pletely coated over upon its internal surface, with a more or less thick 
false membrane, which reduces material!} 7 its calibre, and impedes to a 
greater extent the passage of air, than does the mere inflammatory tur- 
gescence and swelling of the mucous membrane of the organ in severe 
spasmodic croup. On this account, therefore, the stridor in the respira- 
tion is louder, shriller, more persistent, more marked in the expiration, 
and attended with greater effort of the respiratory muscles to overcome 
the obstacle to the passage of the air in membranous than in severe spas- 
modic croup. We may add that there is something very peculiar in the 



78 SPASMODIC SIMPLE LARYNGITIS. 

cough in true croup. When the membrane has come to cover the inte- 
rior of the larynx, the cough is very distinctive; it has a sound which we 
can describe only by saying that it alwa} T s reminds us of the sneezing of 
a 3'oung kitten. This we have never heard in catarrhal croup, no matter 
how severe. 

To conclude, there is in membranous croup a slow, steady, and unre- 
lenting progression of the symptoms, which is not observed in the spas- 
modic disease. From hour to hour, from day to day, we can perceive, so 
to speak, from the gradual and steacVy march of the disease, that a for- 
eign body in the form of a fibrinous moulding, is being spread slowly 
over the cavity of the laiynx. In severe spasmodic croup, on the con- 
traiy, the course of the symptoms is less regular ; paroxysms of suffoca- 
tion occur as in true croup, but when these are over, the child is often 
quite comfortable ; the S} T mptoms indicating a much less considerable 
permanent mechanical obstruction than in the other affection. 

Spasmodic laryngitis has been mistaken also for laiyngismus stridulus. 
The manner in which it is to be distinguished, will be described in the 
article on that disease. 

Prognosis. — Spasmodic catarrhal laryngitis is very rarely a fatal dis- 
ease. Of its two forms, there can be no doubt that the severe is much 
more dangerous than the mild, since in the former the patient labors 
under acute inflammation of the larynx, as well as under spasm of that 
organ ; whilst, in the latter, the amount of inflammation is so very slight 
as to be of little or no consequence, were it not associated with the laiyn- 
gismus, which gives to the disorder its most characteristic features. 

Of 109 cases of the disease of which we have kept an accurate record, 
none proved fatal, though 23 of these were of the grave form. We may 
state, also, that we have seen at least 100 more cases, of which we have 
no written account, in none of which was there a fatal termination. We 
have, therefore, never seen a case of croup without false membrane prove 
fatal. That it does sometimes end unfavorably, however, cannot for a 
moment be questioned. There are various examples of the kind scattered 
through the medical journals. MM. Rilliet and Barthez quote, in proof 
of this, two cases from the work of Jurine, in one of which an autopsy 
was made, and no false membrane discovered. Copland (Joe. cit.) re- 
marks, that in the few cases of the more purely spasmodic forms that 
he has had an opportunity of examining, an adhesive glairy fluid with 
patches of vascularity on the epiglottis and laiynx, and a similar fluid 
in the large bronchi, were the only alterations observed. 

Great imminence of danger in any case is shown by a high intensity 
of the stridulous sound, especially as heard in the expiration ; hy great 
severity of the dyspnoea or suffocation ; by permanently whispering voice ; 
by lividity or extreme paleness of the face ; by smallness and rapidity of 
the pulse ; by coldness of the extremities ; and by delirium or convulsions. 

Treatment.— M. Guersent (loc. cit., pp. 367, 368) states that demulcent 
and mucilaginous drinks, with stimulating hand-baths and foot-baths, are 
the principal means that ought to be employed in the treatment of spas- 
modic laryngitis, or pseudo-croup. He proscribes the use of emetics and 



TREATMENT. 79 

leeches as unnecessary in most cases, and is of opinion that they have 
come into general use, in the management of the disease, in consequence 
of its having been generally confounded with true croup. In a paper on 
croup, by the late Dr. Charles D. Meigs (Med. Exam., vol. i, p. 398), may 
be found the following statement in regard to the spasmodic variety: 
"The croup sound often ceases entirely, and never returns after the 
exhibition of a small quantity of ipecacuanha, or any other emetic sub- 
stance, even when no emesis is produced." He sa}*s in another place, 
that " a foot-bath with mustard, and an emetic of ipecacuanha, is in 
general all that is necessary for the cure." 

In giving our own experience in regard to the treatment of this disease, 
we shall speak first exclusively of the mild, and then of the severe form, 
since the measures proper and necessary in the one, are very different 
from those called for in the other. 

Treatment of the Mild Form — Emetics. — The great majority of 
cases will recover perfectly well under the use of emetics employed 
alone, or in combination with warm baths and revulsives. Of late years 
we have often succeeded in warding off the slight attack, where there 
has been good reason to expect it, by the administration of an opiate 
with syrup of ipecacuanha, at bedtime (early in the evening). At two 
years of age, three or four drops of laudanum, with ten to twenty drops 
(according to the gastric susceptibilhVy) of syrup of ipecacuanha; at 
three or four years, five drops of laudanum with twenty of the ipecac- 
uanha, are about the proper doses. Even when the child has had one 
attack earl}' in the night, the use of the opiate is most successful, after 
vomiting, in preventing the usual return towards morning. If the phy- 
sician is not called until the day after the first attack, this treatment is 
excellent in the evening of the second day. In cases attended with 
violent dyspnoea, hoarse cough, and loud stridulous respiration, the 
emetic should be given until it produces a full effect. In milder cases, 
in which there is merely loud croupal cough, with an occasional stridu- 
lous sound, nauseating doses alone will generally suffice. The most suit- 
able emetic is, as a general rule, ipecacuanha. The best preparation for 
children is the syrup, of which from twenty to thirty drops may be given 
to those two years of age, to be repeated every ten or twenty minutes 
until vomiting is produced, or until the paroxysm is relieved. In very 
sudden cases, the Syrupus Scillse Compositus, which is more active in its 
effects in consequence of the tartar emetic which it contains, might be 
preferable ; about twenty drops of this may be given, and repeated every 
ten or fifteen minutes, until vomiting or the resolution of the paroxysm 
is obtained; but, in its employment, care should always be observed not 
to continue it for too long a time, lest it produce the injurious effects of 
tartar emetic. Of late years we have almost entirety abandoned the use 
of this latter emetic, as we succeed perfectly well with the ipecacuanha, 
and dislike more and more the antimonial preparation in children. Y\ hen 
the dyspnoea is very urgent, or when other means fail to produce emesis, 
we have found nothing so effectual as powdered alum, in doses of a tea- 
spoonful mixed with honey or molasses. (See Treatment 0/ pseu Jo-mem- 
branous laryngitis.) 



80 SPASMODIC SIMPLE LARYNGITIS. 

A simple and good method of treating the paroxysm is that recom- 
mended by Dr. Charles D. Meigs, in the paper referred to. It is to direct 
a small teaspoonfnl of powdered ipecacuanha to be diffused in a wine- 
glassful of water, of which mixture doses of a teaspoonful are to be given 
every ten, fifteen, or twenty minutes, according to the urgency of the 
symptoms. This is a plan of treatment often resorted to by parents in 
this community, where the disease is so common and so well understood, 
that there are few mothers who have several children, and who have had 
some little experience, who do not know how to treat a nocturnal attack 
of mild spasmodic laryngitis. 

After the paroxysm is relieved, it is a good plan to direct five or ten 
drops of the ipecacuanha syrup to be given eveiy two or three hours 
during the following day; or, if the child seems perfectly well in the 
morning, we may begin with these doses in the middle of the da}', and 
continue them until bedtime. By this method, the recurrence of the 
paroxysm during the second night ma}', we think, often be prevented, 
and the cough is rendered free and loose much sooner than when the 
disorder is left to pursue its natural course. Moreover, the child ought 
to be kept in the house during the next two or three days, or until the 
cough is thoroughly loose and easy. If the child be at all a delicate 
one, or one in whom the disorder is prone to be obstinate, there is no 
plan so good as to make it sit or lie quietly in bed, sufficiently covered, 
with a large abundance of playthings, or with a kind nurse to read to 
and amuse it for two or three days. 

Baths. — The warm bath is a very prompt and useful remedy in the dis- 
ease. In all very violent cases, it ought to be resorted to immediately. 
It should be used also whenever the emetic fails to relieve the urgency of 
the symptoms, and in cases attendant with much disturbance of the cir- 
culation. The temperature of the water ought to be about 95° Fahren- 
heit, when the child is first immersed, to be raised gradually by the addi- 
tion of hot water, to 100° or 102°. The child may remain in the bath 
from ten to twenty minutes. 

Bloodletting. — Depletion is never necessary in mild spasmodic croup. 
The only cases that call for it are those in which the symptoms tend to 
assume the features of the grave form. Under such circumstances, the 
method of treatment would be the same as that proper for this latter 
affection, to the description of which the reader is referred for further 
in format ion. 

Revulsives. — The only revulsives that it can be necessary to employ are 
mustard foot-baths or mustard poultices applied to the interscapular space ; 
and even these are often needless if the emetic be given. Blisters, which 
are recommended by some of the French writers, can only be proper in 
rare cases of the grave form. 

Purgatives are required when constipation is present, or when there is 
so much fever on the second or third day, as to show a considerable 
amount of laryngeal inflammation. Under the latter circumstances some 
mild remedy of this class may be resorted to with a view to its evacuant 
effect. We have never had occasion to employ any of the mercurials, and 
believe them to be unnecessary. 



TREATMENT. 81 

Opium is exceedingly beneficial when the emetic, nauseant, or warm 
bath have failed to relieve entirely, and when a troublesome croupal congh 
continues after the spasm has been overcome. Laudanum, paregoric, or 
solution of morphia, in combination with syrup of ipecacuanha or hive 
syrup, or Dover's powder alone, are the most suitable preparations. It 
is a very good plan to give the child a moderately full dose of the opiate, 
with ipecacuanha, after the violence of the paroxysm has subsided. It 
puts the child to sleep, promotes perspiration, softens the cough, and 
tends to prevent the return of the spasm. Repeated once or twice early 
in the second night after the first attack, we believe it often assists 
materially to avert the recurring nocturnal paroxysm. 

Treatment of the Severe Form. — This form of spasmodic laryn- 
gitis requires more active measures than the mild form of the disease. 

In the last edition of this work, bloodletting was recommended when 
the disorder occurred in robust and vigorous children, and a record was 
given of the employment of venesection in seven out of twenty-three 
cases, all of which recovered. Since that report we have learned that 
depletion is less necessaiy than we formerly supposed, and, as we can 
still say that we have never yet seen a fatal case of spasmodic croup, 
either simple or severe, it is fair to conclude that the disease can be safely 
managed without a resort to this more violent measure. Still, it is but 
proper to state, that should a case occur to us in a strong and healthy 
child, in which the breathing should become so much obstructed as to 
cause deep and alarming venous stasis, and in which these symptoms 
resisted the more simple means we now employ, w T e should not hesitate 
again, as in former 3-ears, to employ a venesection to the extent of four 
ounces at the age of four or five years, or a leeching to the same amount. 

Since our last edition was published, we have learned also that calomel 
is less necessary than we then supposed. In fact, we rarely use it at all 
in these affections nowadays. 

Our favorite remedies of late years have been emetics, opiates, salines, 
and the sulphurated antimony of the recent Pharmacopoeia. When the 
patient is a vigorous child, and over a year old, we generally employ the 
following combination: 

R. — Antimon. Sulphurat., gr. j. 

Pulv. Doveri, ........ gr. iij. 

Sacch. Alb., gr. xij. 

M. et div. in chart, xij. 

Of these powders one may be given every two, three, or four hours, 
care being taken to suspend the antimony when it produces any of the 
peculiar distress or general prostration to be described in the article on 
pneumonia. In such a case, we use the following combination : 

R.— Potass. Citrat,, . . . . ( . . ^ . £j. 
Syrup Ipecacuanhae, ....... fgij- 

Tr. Opii Deodorat., gtt. xij. 

Syrup Simp., fgij. 

Aq., 

Dose for a child two years old, a teaspoonful every two hours. 

6 



82 SPASMODIC SIMPLE LARYNGITIS. 

In older children, both the potash and opiate may be doubled. In all 
these cases an emetic ought to be given once, or two or three times in 
twenty-four hours, when the dyspnoea and stridor become very severe ; 
and in about an hour after its operation, the saline dose should be resumed. 
Of course, if decided drowsiness supervene from the opiate, the doses 
must be given at longer intervals. The emetic treatment is not so essen- 
tial as in true croup, where it is so useful in causing the rejection of the 
false membrane which obstructs the larynx. Yet it is exceedingly useful, 
and often indispensable, in assisting to expel the viscid mucus secreted 
within the laiynx, and in relaxing, for a time at least, the spasmodic con- 
striction of the glottis, which plays a most important part in the produc- 
tion of the distressing d} T spncea and suffocation of the disease. The}- act 
probably also by lessening immediately, or through their action on the 
circulatory and nervous systems, the inflammation of the larynx. For 
their choice and mode of administration, the reader is referred to the 
article on true croup. 

Purgatives are required merely to keep the bowels soluble ; they should 
be repeated as may be necessary throughout the disease. If the bowels 
are moved every da} r or eveiy other day spontaneously, there is no use 
in giving them at all. The most suitable are castor-oil, rhubarb, or mag- 
nesia, in small doses ; or an enema may be given from time to time if the 
child does not resist its application. 

Expectorants are useful after the violence of the disease has been mod- 
erated by more energetic remedies. They may consist of small doses of 
ipecacuanha, of antimonial wine and sweet spirits of nitre, of decoction 
of seneka, snake-root, or of the citrate or carbonate of potash. 

Opiates are necessaiy, and are serviceable, as has already been stated, 
in calming excessive restlessness, and in allaying the violence of the suf- 
focative attacks, which depend, in good part, on spasm of the glottis. 
The most suitable are Dover's powder or some other preparation of opium, 
or small doses of belladonna, or hyoscyamus. 

Belladonna would seem, from its power to relax the sphincters, and 
from its excellent effects in hooping-cough, to be indicated in this disease, 
but we have succeeded so well with opium that we have not often used bel- 
ladonna. Probably a combination of the two would be found beneficial. 

A warm bath at 97°, or 98°, empkyed once or twice a day, and con- 
tinued for a period of ten or fifteen minutes, often assists greatly in less- 
ening the sufferings of the child, in calming restlessness, and in moder- 
ating the heat of skin and violence of the circulation, when the latter 
symptoms are strongly marked. The same effects may often be obtained 
by the use of counter-irritants, as sinapisms, mustard poultices, mustard 
foot-baths, &c. Blisters are of doubtful propriety in any cases. 

Hygienic Treatment. — In either form of the disease the child should 
be placed for the time in a warm room, and warmly clothed. If old 
enough, it ought to be kept as much as possible in bed during the par- 
oxysm. If so young as to prefer the lap of the nurse, it should be clothed 
in a long loose wrapper in addition to its usual night-dress. It is very 
important to confine the child during the whole term of the acute period 



TREATMENT. 83 

in the bed. if it is over three or four years old, and in the crib or lap, if 
it be younger. Even after the cessation of the acute condition, it ought 
to be kept in the house for a few days, in order to make sure of the con- 
valescence. The diet must be simple and of easy digestion, so long as 
there is any disposition to recurrence of the disease. It may consist of 
preparations of milk, of bread, rice, or of thin chicken or mutton water. 
Meat and most vegetables had better be avoided, until the convalescence 
is fairly established. 

Prophylactic Treatment. — It is certain that much may be done by 
a wise attention to physical education, to prevent attacks of the disease 
in children who show a liability to it. We would strongly recommend, 
with this view, attention to the following advice given by M. Guersent, 
who says (loc. czY., p. 381) : " It is possible, to a certain extent, to prevent 
attacks of pseudo-croup, if we fortify the constitutions of children, by 
exposing them well-clothed to a dry and elastic atmosphere, particularly 
if the} T can be kept in constant movement. But of all the precautions 
which have been found unquestionably advantageous, that which seems 
most useful is to make them sleep in well- ventilated, dry, carefully closed 
chambers, having a southern exposure, and always without fire. We 
have several times been convinced of the utility of this habit in families 
the children of which were subject to this kind of catarrh." 

There can be no doubt that the style of dress used for children in this 
country, must occasion many and repeated attacks of croup which might 
just as well have been avoided. The custom is to dress children between 
the ages of one and four or five years, in such a way as to expose to the 
air, the whole of the neck and the upper half of the thorax (for the dresses 
are made so low and loose at the shoulders, as to leave the upper part of 
the chest virtually uncovered). The arms are left bare, as are also the 
legs from the knee, or above the knee, to the ankle, so that very nearly 
half of the cutaneous surface is without covering, and this, too, in the very 
same rooms and temperature in which sit the parents with the body and 
limbs warmly clothed to resist our climate, at all seasons changeable and 
uncertain, and, in the winter, very cold. We are perfectly well convinced 
that this faulty and unreasonable system of dress, which is chosen because 
it is the fashion, or in order to harden the child, who, however, invariably 
puts on warm clothing when it comes to years of discretion, will explain 
in part the enormously greater frequency in children than in adults, of 
the various diseases of the air-passages and lungs produced by cold. 

One of the most important means of prevention, therefore, is the adop- 
tion of a suitable dress. In winter this should consist of one that shall 
cover the body completely. If the child be at all delicate, it ought to 
wear next to the skin a woollen jacket with long sleeves, and covering the 
chest to the neck. Over this should be put a long-sleeved stout muslin 
dress, or one of some light woollen material, made in the same style. In 
young children, the stockings ought to be of wool, and should reach to 
the knees ; in older ones, they may be shorter, but the legs should be 
covered with drawers made of canton flannel, of thick cotton stuff, or of 
light woollen flannel. To show the influence of dress, Dr. Eberle men- 



84 PSEUDO-MEMBRANOUS LARYNGITIS. 

tions the fact that in the country, and especially amongst the Germans, 
who cover the neck and breast, croup is a very rare disease. During a 
practice of six years amongst that class of people, he met with only one 
case of the disease. 

When the liability to the disease continues after the completion of the 
first dentition, we have found the daily use of the cold bath, in connec- 
tion always with warm clothiug, most useful in preventing the attacks. 
The bath must be commenced with in the summer, and persevered in 
through the following winter. The water, after the cold weather begins, 
should be drawn in the evening, allowed to stand all night in a room in 
which there is a fire through the day, and made use of on the following 
day. Prepared in this way, we have found the water in the morning at a 
temperature of between 50° and 60° P. The child ought to be kept in 
the water only half a minute or a minute, then well rubbed, and dressed 
immediately. 

When the child is pale, weak, and feeble, and unable to bear exposure 
to the outer air, it may generally be restored to much better health by 
careful attention to diet, and by the steady and long-continued use of 
some tonic remedy. The diet ought to consist of bread and milk, and of 
meat and the simpler vegetables, as potatoes and rice. The tonics most 
generally suitable are quinine or iron. Of the quinine a grain may be 
given in pill or solution, twice or three times a day ; while at dinner or 
lunch, or at both, the child should be made to drink from a dessert to 
a tablespoonful of port wine, mixed with water. This method ought to 
be steadily persevered in for from three to six weeks or longer. If qui- 
nine be objectionable for auy reason, iron must be substituted. The best 
preparations are the iodide or the metallic iron. 



AKTICLE III. 



Definition and Synonymes. — Pseudo-membranous laryngitis is an 
acute inflammation of the mucous membrane of the larynx, attended with 
the exudation of false membrane. 

It is the croup of the French writers, while, in this country, it is called 
by the various names of slow, creeping, true, membranous or inflamma- 
tory. The term given above seems most suitable, as expressive of the 
real nature and seat of the disease, and we shall, therefore, make use of 
it in contradistinction to that of spasmodic laryngitis or spasmodic or 
false croup, which is a much more common and less dangerous affection. 

Nature and Relations — By most authorities, true croup is regarded 
as an idiopathic primary inflammation, presenting the unusual result of 
pseudo-membranous exudation, and differing thus from diphtheritic 
croup, which is a mere complication in the course of a constitutional dis- 
ease, depending upon the extension of the false membrane from the 
fauces into the larynx. 



NATURE AND RELATIONS. 85 

The considerations upon which this distinction is based ma}^be briefly 
stated as follows : that true croup is a disease peculiar to childhood, and 
that many of its peculiarities are to be explained by reference to the 
development of the larynx at that period ; that it is not connected with 
any special alteration of the blood crasis ; that it nearly always com- 
mences in the laiynx, and, though it may pass downwards into the 
trachea, never passes upwards into the pharynx ; and finally, that it does 
not present the complications of diphtheria, such as albuminuria and 
pseudo-membranous exudation on abraded surfaces, nor its characteristic 
paralytic sequela?. 

So far as the mere anatomical conditions are concerned, it is generally 
conceded that there is no essential difference between primary croup and 
pseudo-membranous croup occurring in the course of diphtheria. The 
attempt was made by M. Isambert to base a distinction between the two 
affections upon the ulcerated condition of the mucous membrane of the 
larynx in diphtheritic croup, but West has met with similar ulceration in 
cases of primary croup, though somewhat less frequently than in the sec- 
ondary diphtheritic form. 

But further, our personal experience constrains us to state that the 
differences between the two forms of membranous croup above enumer- 
ated, have not seemed to us sufficiently marked and constant to positively 
establish their essential diversity ; and that it is our decided opinion that 
the vast majority, if not all, of the cases usually termed pseudo-mem- 
branous laryngitis are in reality instances of primary laryngeal diph- 
theria, in which the constitutional symptoms are not grave, and where 
the faucial deposit has been very slight and perhaps even overlooked. 

We are led to this conviction especially b}^ the repeated observation of 
cases in private practice, where we have been summoned upon the first 
sj'mptoms of indisposition, and have found a trifling amount of mem- 
branous exudation on the fauces, which, in a day or two, had disappeared, 
while the symptoms of croup supervened. 

Apart from their sporadic occurrence, we confess that we are altogether 
unable to detect any difference between such cases and the cases of so- 
called primary laryngeal diphtheria, frequently met with in epidemics of 
diphtheria, where the angina is but trifling, and is rapidly followed by 
pseudo-membranous formation in the larynx. 

It is true that the primary sporadic form of croup we are now discuss- 
ing occurs more exclusively in children than does the more fuhy de- 
veloped form of diphtheria ; but it must be remembered that in childhood 
there seems to be a peculiar tendency for the laiynx to become involved 
in the course of diphtheria, and also that a comparatively trifling amount 
of membranous exudation in a child's larynx will produce grave symp- 
toms of obstruction. 

It is also true that these sporadic cases are rarely attended with al- 
buminuria or followed by paralytic sequela? ; but when we consider the 
remarkable variations in the frequency of these conditions in different 
epidemics of diphtheria, it is not inconsistent that they should be usually 
absent in mild sporadic cases. 



86 



PSEUDO -MEMBRANOUS LARYNGITIS. 



It is not our intention in the above remarks to denj^ the possibility of 
pseudo-membranous laryngitis occurring as a purely primary idiopathic 
affection, and we have consequently treated of it as a special disease, 
apart from the brief notice of it we have given in the article on diph- 
theria. 

But the considerations which we wish to impress deeply upon the mind 
of the reader are, that in the vast majority of cases of true croup careful 
examination of the throat at an early period of the attack will show the 
presence of exudation on the tonsils or pharynx; and that, consequently, 
whenever a child is taken sick with even the most trifling croupy symp- 
toms, the throat should be immediately and repeatedly examined, and, if 
any membranous exudation be detected, the case should be regarded as 
probably one of membranous croup, a most guarded prognosis accord- 
ingly given, and the most careful treatment immediately instituted. 

Frequency. — The mortality from this disease is in all years consider- 
able, as will be seen from the subjoined table : 



Years. 


Mortality 




from Croup 


1838, 


. 101 


1839, 


. 83 


1840, 


. 79 


1841, 


. 100 


1842, 


. 137 


1843, 


. 129 


1844, 


. 179 


1845, 


. 176 


1846, 


. Ill 


1847, 


. 121 


1848, 


. 177 


1849, 


. 130 


1850, 


. 151 


1851, 


. 180 


1852, 


. 208 


1853, 


. 303 


1854, 


. 304 


1855, 


. 265 


1856, 


. 268 


1857, 


. 256 


1858, 


. 292 


1859, 


. 312 


1860, 


. 354 


1861, 


. 304 


1862, 


. 258 


1863, 


. 443 


1864, 


. 455 


1865, 


. 350 


1866, 


. 239 


1867, 


. 185 


1868, 


. 206 



Mortality 
from Diphtheria. 












































307 
502 
325 
434 
357 
260 
192 
118 
118 



Total Mortality, 
less Stillborn. 

4,118 

4,765 

4,593 

5,456 

5,558 

5,155 

5,187 

5,882 

5,944 

6,881 

7,268 

8,989 

8,034 

8,374 

9,745 

9,184 
11,280 

9,906 
11,720 
10,331 
10,162 

9,084 
10,849 
13,838 
14,386 
15,045 
16,794 
16,453 
16,005 
13,153 
13,949 



It is difficult to estimate the number of deaths due to this affection 
during the last nine years, since diphtheria has made its appearance in 



PREDISPOSING- CAUSES. 87 

the mortality lists of the city, as many cases of diphtheritic croup have 
unquestionably been returned as mere pseudo-membranous laryngitis. 

True croup is, however, rare in comparison with false croup, since while 
we have seen but 35 cases of pseudo-membranous laryngitis, we have met 
with upwards of 200 of the catarrhal form. In the following remarks, and 
in those on the causes of croup, we refer the reader also to the table in 
the article on diphtheria, showing the comparative monthly and annual 
mortalities from these two diseases. 

From a glance at the accompanying table, it will be seen that since the 
prevalence of diphtheria, the mortality from croup has not increased dis- 
proportionately to the increase in general mortality ; and that, during the 
past three years, in which there was a marked decrease in general mor- 
tality, despite the occurrence of over 100 deaths from diphtheria in each 
year, the mortality from croup has also fallen even below the average sus- 
tained for many years previous to the appearance of diphtheria in the 
mortality lists. Xo change whatever has occurred in the type of this dis- 
ease during the past ten years, for the experience of one of us for a number 
of years before the term diphtheria came into use and appeared in the 
mortality returns of this city, enables us to attest the fact that pseudo- 
membranous laryngitis, both of the primary and of the more grave diph- 
theritic form, occurred then precisely as it does now. 

Predisposing Causes — Age. — The disease is far most frequent be- 
tween the close of the first and fifth years. Thus of 2136 fatal cases re- 
ported in this city during the past 1 years, 301 were under 1 year of age ; 
571 between 1 and 2 years ; 951 between 2 and 5 years ; or, 1522 between 
1 and 5 years ; and 236 between 5 and 10 years; leaving but 11 cases as 
occurring after the latter period of life. 

Of the 35 cases that we have seen, 28 occurred between 2 and 1 years 
of age, while of the remaining f, 1 occurred at the age of 18 months, 1 at 
that of 19 months, 1 at 11 years, 2 at 11 years, and 1 each at 111 and 12J 
years. 

Sex cannot be said to exercise any decided influence upon the fre- 
quency of the disease. Thus of the above 2136 cases, 1115 occurred in 
males, 1021 in females. 

Constitution. — A feeble and delicate constitution is thought by some 
to be a powerful predisposing cause, but this is at least very doubtful. 

Of the 35 cases referred to, 26 occurred in healthy vigorous children, 
while the remaining 9 occurred in children who, though neither very weak 
nor very sickly, presented a rather delicate appearance. 

Season exerts a very powerful influence upon the development of croup. 
Thus the mortality from it attains its maximum during the months of 
November, December, and January, during which quarter about four 
times as many deaths occur from croup as during the months of June, 
Jul}-, and August. It is, however, comparatively frequent from October 
to March inclusive. 

The relation between the mortality from croup and the temperature 
appears to be a definite and quite constant one, since, as will be seen by 
referring to the table in the article on diphtheria, with the single exeep- 



88 PSEUDO-MEMBRANOUS LARYNGITIS. 

tion of February, the mean monthly temperature and the mean monthly 
mortalit} T from croup rise and fall together throughout the entire year. 

The exciting causes are but little understood. The only ones which 
seem to have been ascertained with airv certainty, are the application of 
irritating agents to the laryngeal mucous membrane, and exposure to cold, 
and even these are questioned by the most accurate observers. In none 
of the cases that we have seen could the exciting cause be even suspected. 

Second Attacks of membranous croup, though rare, are mentioned 
as occurring by several authors ; and, in our remarks on tracheotomy, we 
quote from Millard an allusion to five cases, in each of which the operation 
was twice successfully performed for successive attacks of this disease. 

"We have ourselves met with two instances in which second attacks oc- 
curred. One was a girl, who had her first attack at the age of 11^ years, 
and her second at the age of 12J, and recovered from both without the 
operation. The second patient was a boy, who had his first attack, a very 
severe one, but from which he recovered without tracheotomy, at the age 
of 5^ years ; and his second attack, which is fully detailed at the end of 
the article on Tracheotomy (Case 1) at the age of 7 } years. 

Anatomical Lesions. — The false membrane ma} T cover the whole 
mucous membrane of the larynx, and extend into the pharynx, trachea, 
and bronchia; or it may be confined to the laiynx, either forming a 
complete lining to the cavity of that organ, or consisting merely of 
patches of various sizes, with intervals of mucous membrane destitute 
of exudation. 

It is, in the first place, important to ascertain the proportion -of cases 
in which the deposit extends into the bronchia, and those in which it 
remains limited to the larynx, or laiynx and trachea, as the determina- 
tion of this point has some bearing upon the question of the propriety 
of the operation of tracheotomy. It appears from a table given by M. 
Guersent (Diet, de Medecine, t. ix, p. 346), containing the results of cases 
collected b} r M. Hussenot from various sources, and of autopsies made 
by M. Bretonneau, numbering in all 111, that in 78 the membrane did 
not extend beyond the trachea, and that in 42 it invaded the bronchia, 
and in 30 the condition of the bronchia was not mentioned; and in 21 
there were no false membranes ; so that of 120 cases, in which the extent 
of the false membrane was accurately noted, it was confined to the 
larynx and trachea in 78, and extended into the bronchia only in 42; or 
in about one-third of the cases. This proportion is the same that Millard 
gives (De la Tracheotomie dans le cas de Croup, These de Paris, 1858), 
in his masterly memoir upon croup, after an analysis of a large series of 
cases. Our own experience, based upon 10 cases in which we ascertained 
with exactitude (by autopsy and by tracheotomy) the extent of the mem- 
brane, would indicate that it passed into the bronchia in a larger propor- 
tion of cases ; since in 5 of these 10 cases the exudation extended be3 T oncl 
the trachea. It is to be borne in mind, however, that the cases upon 
which these calculations are based have very frequent^ resulted fatally, 
and presented extensive formation of pseudo-membrane in the bronchia; 
and it is probable that it really exists there in other instances, but to 



ANATOMICAL LESIONS. 89 

a much less extent, so that recovery takes place, and renders it impossi- 
ble to determine accurately the extent of the exudation. 

The proportion of cases in which the pharynx is implicated is also im- 
portant, since it affects the diagnosis of the disease, and indeed bears 
upon the question of the identity or non-identity of pseudo-membranous 
laryngitis and diphtheritic croup. 

In considering the statements of authors upon this subject, it is evident 
that much of the diversity in their opinions depends upon the fact, that 
they are not in reality all referring exclusively to this particular affection. 
Thus the assertion of M. Guersent {Diet, de Med., t. ix, p. 339), that in 
nineteen-twentieths of the cases the exudation begins in the pharynx, is 
evidently to be explained on the supposition that this distinguished prac- 
titioner had been observing a series of cases of diphtheria in which the 
exudation had extended into the larynx. MM. Rilliet and Barthez, on the 
other hand, state that a majority of the cases observed by themselves, and 
of those of M. Hache also, commenced in the larynx. Dr. West also re- 
ports 11 cases of idiopathic croup, in onty two of which was there any 
formation of false membrane upon the velum and tonsils. 

In 31 cases observed by ourselves, in which the condition of the throat 
was recorded, the croup followed membranous angina in 21 cases; in 5 
the disease began in the larynx, but was attended later with small de- 
posits upon the tonsils ; and in 5 only was there no deposit on the throat 
at any time. 

The fauces and pharynx do not present any constant alterations in 
cases of croup. Frequently, however, the mucous membrane is red and 
swollen, and there may be patches of membranous exudation upon the 
tonsils, velum, half-arches, or on the pharynx. These patches are usually 
thin, whitish, and may not persist more than 24 to 48 hours, disappearing 
and being succeeded by similar formations in some other part of the 
throat. 

We believe indeed that such patches of exudation will be found in a 
large proportion of cases during the first two or three days of the attack; 
and that thej^ are not more frequently observed, chiefly because the 
symptoms are usually so slight during this stage, that either no medical 
attendant is summoned, or his attention is not attracted to the throat. 

The most important and characteristic morbid appearances are, how- 
ever, to be found below the glottis, and consist in the presence of pseudo- 
membranous exudation, and of certain alterations in the respiratory 
mucous membrane. 

The false membrane may be limited to the larynx, or to the larynx and 
trachea; or it may extend over these parts and into the branches of the 
bronchi, even to the third and fourth division. In the larynx, trachea, 
and even the primitive bronchi, it may appear merely as patches of vari- 
ous sizes, with intervening spaces of vascular mucous membrane; but in 
the smaller air-passages it usually takes the form of complete tubes Lining 
the bronchus. In some cases, such tubular casts may be formed con- 
tinuously from the larynx down to the minute bronchioles, completely lin- 
ing the air-passages. It is undoubted, that in the more sthenic idiopathic 



90 PSEUDO-MEMBRANOUS LARYNGITIS. 

form of membranous laryngitis, the membrane is more apt to extend 
deeply into the ramifications of the bronchi, than when it occurs as a 
complication of diphtheria. 

The false membrane is commonly of a j^ellowish-white color, and from 
a fifth of a line to a line in thickness. Its consistence is generally con- 
siderable, and it is usually somewhat elastic; indeed the more white and 
fibrous varieties possess a degree of firmness and toughness that renders 
it difficult to tear the membrane, or teaze it out with needles. It is an 
almost invariable rale, that the membrane lining the upper part of the 
air-passages is more white and firm than that found in the smaller 
bronchi; so that it frequently happens, that, on drawing out the firm 
white tubular membrane lining the larynx, trachea, and primary bronchi, 
it is seen to terminate in branches which grow progressively softer, more 
yellow and purulent, as they become smaller and smaller. 

The free surface of the pseudo-membrane is usually covered with puri- 
form mucus, while the attached surface is adherent with various degrees 
of force to the mucous membrane beneath. The strength and closeness 
of these adhesions are often proportionate to the firmness and toughness 
of the false membrane itself. In the larynx and trachea it is often neces- 
sary to employ a good deal of force to separate the exudation from the 
mucous membrane, and innumerable little fibres are seen passing from 
one to the other, as though they were processes of exudation clipping 
into the minute orifices of the mucous follicles. On the other hand, the 
adhesion between the exudation and mucous membrane is rarely close in 
the smaller bronchi, or in cases where the pseudo-membrane in the larynx 
and trachea is less firm and consistent. 

These false membranes consist, according to Hasse, mainly of fibrin 
blended with mucus in various proportions. {Path. Anat., Syclen. Soc. ed., 
p. 278.) On microscopic examination, they present a more or less close 
fibrous basis, consisting of interwoven fine fibrils, with imbedded cells 
in varying number; these cells presenting the ordinary appearances of 
exudation corpuscles, being round, granular,. and containing from one to 
three small nuclei. The action of various chemical reagents upon them 
will be found detailed in the article on diphtheria. 

The mucous membrane beneath the exudation presents various shades 
of redness, or it is purplish, or even ecclrvmosed and blackish. It is also 
swollen, and may be slightly softened or friable, and has a dull excoriated 
appearance, though actual ulceration very rarely exists. West mentions 
the occurrence of small aphthous ulcers about the edges of the rirna glot- 
tidis and the arytenoid cartilages, as a frequent lesion in idiopathic 
croup ; but the same lesion has been observed in the diphtheritic form of 
the disease. 

There is also vascularity, though usually to a less marked degree, of 
the bronchial mucous membrane at the points where no exudation exists. 

The lungs present some abnormal condition in the great majority of 
cases. Bronchitis and pneumonia are frequent complications of the dis- 
ease; and in addition there is often collapse of larger or smaller portions 
of lung-tissue from occlusion of some bronchus by the pseudo-membrane. 



SYMPTOMS. 91 

In other instances, or frequently in conjunction with collapse of portions 
of the lungs, the violent respiratory efforts induce either vesicular or even 
interstitial emphysema, especially of the anterior borders of the lungs. 

The morbid appearances found in cases where the croup has followed 
diphtheritic angina, will be fully described under the head of this latter 
disease. 

In the secondary croup of measles, the appearances are very similar to 
those observed in primary cases, while in that of scarlet fever the exuda- 
tion differs in being less consistent and less uniformly spread over the 
diseased part. In the last-named malady, the membrane is thinner and 
less adherent, and, in some cases, puriform, soft, and of a grayish color. 
It is usually poor in fibrin, and prone to decomposition. The mucous 
membrane is generally discolored and softened. 

Symptoms. — In the majority of cases, the development of the symptoms 
characteristic of croup is preceded for a few days by the ordinary symp- 
toms of catarrh and slight sore throat. The child is feverish and drowsy; 
there is cough, which may possess a slight croupy character at some period 
of the twenty-four hours, but more frequently seems like an ordinary ca- 
tarrhal cough; coryza is very rarely present, but there is slight soreness 
behind the angles of the jaws, and the fauces are seen to be reddened, 
and probably small, thin patches of pseudo-membrane may be visible on 
the tonsils or fauces. This early stage lasts a variable time, usually from 
one to three or four days, and is more or less gradually succeeded by the 
symptoms indicative of laryngeal obstruction. 

"When, on the other hand, the disease begins in the huynx, the invasion 
is marked by hoarseness of the voice, and hoarse, croupal cough, which 
often continue for one, two, or three days, until the disease has made 
considerable progress, before the parents deem it necessary to send for a 
physician. In a case that came under the observation of one of ourselves, 
the child was playing about the room at a time when he had hoarse, whis- 
pering voice, and cough, and stridulous respiration. In another we were 
not called until the evening of the third clay, though the child had had 
stridulous cough and respiration for two nights ; but, as he always seemed 
better in the morning, it was not thought necessary to send for a physi- 
cian, until after he had become violently ill. In a third case there was 
hoarseness of the voice and slight croupal cough during the afternoon of 
one day and the ensuing night, and the next morning fully developed 
croup, with fibrinous patches on each tonsil. These symptoms are not 
generally accompanied by fever at first. The appetite is usually unim- 
paired, the thirst scarcely augmented, and the child, though somewhat 
dull and languid, is disposed to be amused at times. In other and severer 
cases, on the contrary, the disease becomes aggravated much more rap- 
idly, and may soon lead to a fatal termination. 

The change of the voice is the first symptom observed in the cases 
which begin in the larynx. It has always been described to us as hoarse, 
like that which is heard in an ordinary cold. As the disease progresses, 
the voice becomes more and more hoarse and difficult, until at length it 
is reduced to a mere whisper. The degree of the hoarseness varies, how- 



92 PSEUDO -MEMBRANOUS LARYNGITIS. 

ever, to a very great degree in the same case, the diversities depending 
probably upon the amount of the spasm of the laiwnx at the moment, and 
upon the state of the exudation. We have several times observed the 
voice to become much stronger and clearer after the operation of an 
emetic, in consequence no doubt of its relaxing effect upon the glottis. 
The cough is peculiar. At first slightly hoarse, it becomes, as the case 
goes on, very hoarse and hollow, and then short and smothered. It is 
variable in frequency, and is apt to occur in paroxysms, which are often 
very troublesome from their frequent recurrence. Towards the termina- 
tion of the disease in fatal cases, or whenever the case is very severe, it 
is altogether different in character from what it was at the beginning, be- 
coming short, instantaneous, and smothered, so that it might very well 
be called whispering. As the disease progresses, it is accompanied by 
stridulous respiration, in which a hoarse, rough, hissing, or crowing sound 
is produced b}' the rush of the air through the constricted larynx. This 
sound is usually heard at first only during forced inspirations, and is 
therefore noticed first during the long inspiration which precedes cough- 
ing. Xext it is heard during the violent respiratory movements which 
aecompanjr the act of crying ; and as the laiynx becomes more and more 
clogged with the exudation, it occurs during both inspiration and expi- 
ration, in eveiy act of respiration, and is so loud as to be heard over the 
whole room, or even in adjoining rooms. 

The respiration is natural in the early part of the attack, but as the 
voice and cough assume their characteristic features, and the stridulous 
sound is established, it becomes more frequent, rising to 28, 32, 40, and 
48 in the minute. At first easy and natural, it becomes, during the height 
of the symptoms, and especially in fatal cases, the most frightful dyspnoea 
we have seen in any disease. Every movement of inspiration requires the 
whole force of the inspirator}^ muscles to lift the walls of the chest, and 
enable the air to find its way through the narrow and obstructed glottis ; 
each expiration, instead of being short and easy, as in health, and in 
nearly all other diseased conditions, requires a slow and laborious con- 
traction of the expiratory muscles to expel from the lungs the air which 
they contain, and which hisses through the larynx with a sound nearly as 
loud as that produced during inspiration. The dyspnoea just described 
is for the most part constant, but exhibits paroxysmal aggravations from 
time to time. 

When a paroxysm of dyspnoea occurs, the expression of the child is 
that of the most terrible anxiety, or of the wildest terror. In some in- 
stances, the face becomes deeply red, then blue, livid, and finally pale 
and white, and for a moment life may seem extinct. In other cases, in 
which the dyspnoea is constant, the face is of a dusky red color, the ex- 
pression anxious and haggard, and the child either lies on its side with 
the head thrown far backwards in a state of somnolence, or constantly 
changes its position from restlessness without noticing anything around it. 

Jacobi (Amer. Jour, of ObsteL, May, 1868, pp. 13-65) lays particular 
stress upon the fact that in membranous croup the dyspnoea exists both 
in inspiration and expiration, whereas in spasmodic catarrhal croup it is 



SYMPTOMS — AUSCULTATION. 93 

chiefly present in inspiration, and is due, be thinks, to paralysis of the 
crieo-arytenoid muscles from oedema and infiltration, so that the vocal 
cords are brought into contact during inspiration. 

There is one further peculiarity about the dyspnoea in membranous 
croup to which we would direct especial notice, since we regard it as of 
the utmost importance. This consists in the occurrence, in certain cases, 
of a deep sulcus around the base of the chest, and of recession of the 
lower part of the sternum and the epigastrium during the act of inspira- 
tion. 

These phenomena are, perhaps, partly due to the violent action of the 
diaphragm, but undoubtedly their chief cause is the atmospheric pressure, 
which acts here, as it has been clearly shown by Jenner to act also in 
rickets to produce the deformities of the thorax characteristic of that 
disease. The normal relation which exists between the firmness and re- 
sistance of the thoracic walls, the power and rapidity of contraction of 
the diaphragm, the elasticity of the lungs, and the size of the orifice of 
the larynx, is here disturbed b}* the greater or less degree of occlusion 
of the larynx by membranous exudation. The calibre of the larynx being 
thus diminished, so that air enters the lungs but slowly, and the dia- 
phragm contracting violently, there will necessarily be recession of the 
softer parts of the chest walls at each inspiration. 

The persistence of these phenomena during inspiration for even a short 
time is, we believe, in the highest degree characteristic of the presence of 
false membranes in the laiynx ; and when, despite the use of emetics, 
this form of respiration continues, it constitutes one of the strongest in- 
dications for the performance of tracheotomy. 

There is no expectoration early in the disease, or it consists of yel- 
lowish viscous mucus. At a later period, there is usually expectoration 
of false membrane, sometimes in the form of a complete tube, or, much 
more frequently, of small, irregular fragments, mixed with mucus, or with 
the matters ejected from the stomach by vomiting. To detect the mem- 
brane, the substances expectorated or vomited ought to be placed in water, 
when the former detaches itself from the mucus and other matters, and 
is easily recognized. It is not voided in all cases in which it is known to 
be present in the laiynx. 

Thus of the 35 cases observed by ourselves, it was expelled by vomiting 
or coughing in 12 ; in 21 none was rejected, though its presence in each 
case was proved by the character of the symptoms and by its existence 
in the fauces, by autopsy, or by the operation of tracheotomy • i n one 
there was expectoration of masses of viscid, yellowish fibrin, though 
none of membrane ; and in one there was no positive evidence of its ex- 
istence. M. Talleix {Guide clu Med. Prat., t. i, p. 330) states that of 
51 cases, in which the symptoms were very carefully observed, no traces 
of the exudation could be discovered either in the expectoration or in 
the matters rejected by vomiting in 26, though its existence was proved 
by post-mortem examination. 

Auscultation. — In the severe cases of true croup that have come 
under our notice, auscultation has been of little or no aid. In fact, the 



94 PSEUDO-MEMBRANOUS LARYNGITIS. 

chest-sounds have been, in most cases, so completely masked by the loud 
shrillness of the laryngeal stridor, that we have been unable to judge with 
any satisfaction to ourselves of the condition of the lungs. It has been 
impossible to determine whether the inability to detect natural respiratory 
murmur depended on the small volume of air that found its way through 
the obstructed larynx, or on the fact that all sound was masked by the 
stridor. This is particularly unfortunate, since, were it not for this cir- 
cumstance, we might be able to judge by auscultation of the extent to 
which the bronchia have been invaded by the false membrane, — a matter 
very important to determine, when the question of tracheotomy comes to 
be mooted in any case. 

In cases in which the laryngeal obstruction is not very great, and the 
stridulous sound consequently less loud, we may auscult the chest to 
some profit. The vesicular murmur is then either natural, or altered ac- 
cording to the state of the lung. 

But, though such has been our own experience in regard to ausculta- 
tion in croup, MM. Barth and Koger (Trait. Prat, d 1 Auscultation, 2eme 
eel., p. 255 and 261) describe, as a sign of croup with floating false mem- 
brane, a kind of vibrating murmur, or tremblotement, as though a movable 
membranous veil were agitated by the respired air, and which can be 
heard when the stethoscope is applied over the larynx or trachea. If this 
sound be heard only in the larnyx, and not in the trachea and bronchia, 
it indicates the plastic exudation to be of small extent, and likely to be 
rejected by expectoration, and the prognosis is favorable. In the other 
case, on the contrary, it shows the disease to be of considerable extent, 
and the prognosis becomes much more serious. 

This question will be found referred to more fully in our remarks on 
the indications for the operation of tracheotomy. 

'There is a slight febrile movement at the onset, or a day or two after 
the appearance of the earliest symptoms. When the disease is fully 
established, the fever becomes violent. The pulse rises to 130, 140, 160, 
or even higher ; it is generally regular and strong at first, but as the case 
progresses, becomes small, feeble, and very rapid. In one of the par- 
ox3 r sms that we witnessed, it became so rapid that it could not be counted, 
and at last ceased to beat at either wrist for a few instants. The heat 
and dryness of the skin are very moderate at first, but increase as the 
disease reaches its maximum, to diminish afterwards gradually, and in 
fatal cases, to be replaced by coldness, with copious clammy perspira- 
tions. The strength is not diminished at first, but as the disease prog- 
resses, becomes more or less so in proportion to the violence and dura- 
tion of the case. The digestive organs are but little disturbed by the 
influence of the disease, with the exception of diminution or loss of appe- 
tite, and moderate thirst, during the violent period. Spontaneous vomit- 
ing or diarrhoea are rare, though both sometimes occur. The tongue is 
moist, and generally covered with yellowish-white fur. Pain in front of 
the larynx has been noticed by several authors. We have ourselves 
observed it in but one case. 

Tumefaction of the submaxillary glands, which is a frequent symptom 



MODE OF RECOVERY — DURATION — DIAGNOSIS. 95 

of pseudo-membranous angina, ought always to be sought for, and when 
present, lends additional support to the diagnosis. 

The mode of recovery in favorable cases is different in different in- 
stances. In some it is sudden, taking place rapidly and steadily after 
the expectoration of a tubular-shaped membrane. The rejection of the 
deposit in this form, is, however, a rare event, and is not always followed 
by recovery. We have seen in this cit} T three distinct tubules of false 
membrane, which were thrown from the larynx of the same child at in- 
tervals of two days each. The first was the largest, and came evidently 
from the whole length of the larynx and trachea ; the second was some- 
what shorter, and the third not more than half so long as the first. The 
child was greatly relieved for some hours on each occasion of the rejec- 
tion of a tubule, but then became more oppressed as the exudation again 
collected. It sank from exhaustion after the third came away. 

As a general rule, the recovery is slow and gradual. After free vomit- 
ing, after the expectoration of fragments of false membrane mixed with 
mucus, or, as happened to ourselves in two cases, after the expectoration 
of masses of tough 3-ellowish fibrin, or, lastly, after the rejection of 
mucoid and frothy sputa only, the symptoms gradually ameliorate; the 
stridulous respiration slowly subsides, and at last disappears ; the cough, 
which was short, hoarse, and smothered, becomes louder, stronger, less 
hoarse, and what is still more favorable, loose ; the aphonia moderates, 
but very slowlv ; the fever disappears ; appetite and ga} 7 ety return ; and 
after a variable length of time, the child enters into full convalescence. 
The hoarseness of voice very generally continues for several days after 
all the other s} T mptoms have lost their dangerous character, and some- 
times lasts for weeks. In one case, the voice was still weak and hoarse 
on the tenth da}', and in another during the seventh week. (See a paper 
on Croup, by J. F. Meigs, M.J)., Am. Jour. Med. Sci., April, 1847.) 

Duration. — Death has been known to occur on the first, second, and 
third clays, but such cases are rare. The duration of the disease may be 
stated at from three to thirteen daj-s, as its most common term. The 
cases seen by ourselves lasted from five to fourteen days. 

Diagnosis. — There can be no difficult} 7 in recognizing the presence of 
pseudo-membranous laryngitis, when the development of the symptoms 
of laryngeal obstruction has been preceded for several days by angina, 
with or without membranous exudation, and hoarseness of voice and 
cough. For the relation which exists between such cases and diphtheritic 
croup, the reader is referred to the remarks at the beginning of this article 
on the nature of croup, and to the remarks made under the head of diag- 
nosis in the article on diphtheria. 

When, however, the disease begins in the larynx, and especially when 
there is no exudation whatever in the fauces, the diagnosis becomes more 
embarrassing, since under these circumstances there are two other laryn- 
geal affections with which true croup may be confounded, — to wit : false 
croup or spasmodic catarrhal laryngitis, and laryngismus stridulus. The 
mode of distinguishing between these different disorders has been care- 
folly described in the remarks on diagnosis, under the head of the former 



96 PSEEDO -MEMBRANOUS LARYNGITIS. 

disease. "We wish in this place merely to call the attention of the reader, 
and particularly of the young practitioner, to the extreme importance of 
the differential diagnosis between the disease now under consideration, 
and false or spasmodic croup, since the former is one of the most danger- 
ous and frightful disorders to which children are subject, demanding vig- 
orous and active treatment from the start, at which period only is medi- 
cal treatment likely to be successful ; whilst the latter, though of a much 
more threatening aspect at the beginning, is in fact a mild and safe disease 
in comparison, and one rarely requiring other than very simple treatment. 

In this connection we would urge again the extreme importance of a 
careful examination of the throat in every case where there are even the 
most trifling croupy symptoms present, since if membranous exudation 
be present either on the pharynx or tonsils, there is great danger that 
the laryngeal symptoms are due to an extension of the false membrane. 

Prognosis. — Pseudo-membranous laryngitis is a very fatal disease. In 
its sporadic form it is decidedly less dangerous than when it occurs in 
the course of epidemic diphtheria, owing to an extension of the exudation 
from the fauces into the larynx, but it still ought, at all times and in all 
shapes, to arouse the utmost caution of the practitioner. 

MM. Rilliet and Barthez state that its common termination is in death. 
M. Yalleix says that "to speak in general terms, it is fatal when not 
treated energetically." M. Guersent (Joe. cit.. p. 365), after a careful con- 
sideration of the statements of various authors, says : " In fact, true 
croup is one of the most dangerous of all diseases ; it is generally fatal." 
He adds that he has seen at least 100 cases of spasmodic croup, without 
a single death, while of 10 children attacked with true croup, it is scarcely 
possible to save two. 

We have ourselves seen upwards of 200 cases of spasmodic or false 
croup, all of which without exception recovered, while of 35 cases of true 
croup that we have seen 16 died. 

The danger is great in proportion as the child is younger and more 
feeble, and in proportion to the rapidity of the case and the degree of the 
dyspnoea. The most unfavorable symptoms are : loud stridulous sound 
heard both in the inspiration and expiration; laborious and prolonged 
expiration; recession of the base of the thorax during inspiration ; whis- 
pering voice or complete aphonia ; congestion of the face and neck ; som- 
nolence ; weak, rapid, and irregular pulse ; cold extremities ; and cold 
clammy perspirations. The favorable symptoms are : expectoration of 
false membranes; diminution of the stridulous respiration; the change 
from whispering to hoarseness or to clearness of the voice; looseness 
of the cough ; moderation of the fever ; improvement of the temper and 
moral state; and amelioration of the general condition. 

The case should not, however, be abandoned as hopeless until life is 
actually extinct. An instance has been elsewhere put on record by one of 
us (see paper by Dr. J. F. Meigs, loe. cit.) of the recovery of a child after 
momentary suspension of animation from asphyxia on two occasions, 
though these attacks were followed by a dreadful illness of two days. 

Treatment. — We are desirous, at the beginning of our remarks upon 



TREATMENT — BLOODLETTING. 97 

the treatment of this disease, to express the opinion, that none is likely 
to succeed, unless it be applied early in the case, and by this we mean, in 
the course of the first, or at the latest, second day. And not only should 
it be commenced early, but the most active remedies ought to be applied 
at this period, in their full force. The very moment there is good reason 
to suppose that a case will prove to be one of membranous croup, the most 
energetic means ought to be brought to bear upon it, and if this be done 
from the first, or even second da}', we cannot but hope that a considerably 
larger proportion of recoveries may take place, than has heretofore been 
thought possible. 

In the study of the treatment, it will be necessary to rely chiefly upon 
the works that have been published since the distinction between the two 
forms of croup has been correct^ drawn, for it is impossible to place much 
dependence on the assertions of previous writers, inasmuch as their opin- 
ions in regard to the effects of treatment must have been formed from in- 
discriminate experience in two very opposite maladies. It is only neces- 
sary to recollect the enormous difference in the mortality of the two affec- 
tions, to be convinced that the success of any plan of treatment in the 
one, is no fair argument for its probable success in the other. Thus M. 
Guersent has seen a hundred cases of spasmodic laryngitis, without a single 
death ; while he believes that of ten cases of the pseudo-membranous form, 
scarcely two can be saved. We have ourselves attended and kept a record 
of one hundred and nine cases of spasmodic croup, and have seen a large 
number of cases besides, of which we have no notes, without a single 
death ; whilst of thirty-five cases of true croup that we have met with, 
sixteeir proved fatal. The most important objects to be held in view in 
the treatment, are the following: to prevent, if this be at all possible, the 
formation of false membrane ; after its production, to cause its dissolution, 
or render it less adherent ; to provoke its expectoration ; to prevent its 
reproduction after it is once expelled ; to subdue the inflammatory dia- 
thesis which exists ; and to allay the painful symptoms. 

Bloodletting. — Many authors award to bloodletting the first place in 
importance amongst the medical means in our possession, and it seems 
to be regarded by many in this country as an indispensable agent in the 
cure. Moreover, there are not a few who believe that, when promptly 
and boldly resorted to, it will seldom fail in arresting the disease. 

The more careful and extended study which this question has received 
during the past few years, however, has led many observers to doubt the 
efficacy of venesection in arresting the course of this inflammation, or 
preventing the formation of membranous exudation. 

In those cases where croup supervenes in the course of epidemic diph- 
theria, there can be no doubt that bloodletting is entirety contraindi- 
cated ; and the same remark may be made of those sporadic cases o( 
pseudo-membranous laryngitis, where the onset of the disease is slow, 
and its course gradual, and unattended by high febrile reaction. Indeed. 
the more wide experience we have ourselves had in the treatment of this 
disease since the publication of the last edition of this work, has con- 
vinced us that bloodletting is, to say the least, unnecessary, excepting 

7 



98 PSEUDO -MEMBRANOUS LARYNGITIS. 

perhaps in cases where the disease occurs suddenly in vigorous children, 
and is attended at an early period of the attack by violent febrile action 
and marked suffocative symptoms. Under such circumstances, and such 
only, it may be advisable to resort to a moderate general venesection, 
principally for the mechanical relief thus afforded to the acute and in- 
tense venous stasis caused by the obstructed respiration. 

For all the other indications, however, for which bleeding was formerly 
recommended in croup, namely, for the reduction of the fever and inflam- 
mation, and for the arrest of the exudative process, we prefer resorting 
to the other remedies hereafter mentioned. 

Emetics. — Emetics are recommended by all writers, and are generally 
acknowledged to be amongst the most, if not the most, efficient of all the 
means employed. M. Yalleix (op. cit,, t. i, p. 358) has demonstrated their 
importance more fully than any other writer. He states that of fifty-three 
cases of the disease, tartar emetic and ipecacuanha were chiefly relied on 
in thirty-one, of which fifteen were cured ; whilst of the twenty-two others, 
in which thej^ were parsimoniously given, but a single one recovered. He 
gives other facts in regard to these cases which are highly interesting and 
important. Thus, of the thiily-one cases treated with powerful emetics, 
false membrane was rejected during the efforts of vomiting in twenty- 
six; and of these, fifteen, or nearly three-fifths, recovered. In the five 
others of the thirty-one, on the contrary, no membrane was expelled, and 
they all terminated fatally. Again, of the twent}~-two cases in which 
emetics formed but a secondary part of the treatment, two rejected false 
membrane, and of these one recovered ; while of the twenty others in 
which no false membrane was expelled, not one escaped. 

Our own experience in regard to emetics has been as follows : They 
were administered frequently and in full doses in thirteen of the twenty- 
one cases which began with angina; in six the}^ were emploj'ed to a mod- 
erate extent, and in two not at all. Of the thirteen cases in which the^- 
were freely administered, eleven recovered ; but, as in one of these life 
was saved only by tracheotomy, the success cannot be attributed to the 
emetics. Of the eight cases in which the emetic plan was not pushed, all 
but one ended fatally. False membrane was rejected in eight out of the 
thirteen cases above referred to. In one of the eight cases the quantity 
rejected was veiy small, and this was the case in which the child was ulti- 
mately saved only by the operation. 

Of thirteen cases in which the disease began in the larynx, emetics 
were energetically used, and frequently employed, in eight. Of the eight, 
five recovered. In four of the eight cases, fragments of false membrane 
were rejected, and in a fifth, a mass of viscid, yellowish fibrin (this case 
was marked as one of unquestionable membranous croup by patches of 
false membrane on the tonsils). Of these five, four recovered. In three 
of the eight, no false membrane was rejected, and of these two died. In 
five of the thirteen cases they were not freely used, being employed in 
two only as a secondary means ; in one other only at the very termina- 
tion of the attack, as we were not called to the case until the tenth day, 
the patient having been under homoeopathic treatment before ; and in the 



TREATMENT — EMETICS. 99 

remaining two cases they were not employed at all. Tracheotomy was 
performed in four of these five cases, but in only one was a successful re- 
sult obtained. 

It is indeed true that there were peculiarities about the age and the 
type of the disease in the above groups of cases which may modify to 
some extent the conclusions which seem inevitable ; but the statements 
aud facts above given are quite sufficient to show that emetics exert a 
most powerful and beneficial influence on the disease, and that they 
ought, therefore, to form a principal and essential part of the treatment. 

The emetics generally employed in Europe and this country are tartar 
emetic and ipecacuanha, which are given in the usual doses to produce 
full vomiting. We would, however, strongly discountenance the emphyy- 
ment of tartar emetic as an emetic, under airy circumstances, in children ; 
and, at least in the disease under consideration, we do not like ipecacu- 
anha as an emetic so well as one which, so far as we know, was first rec- 
ommended by the late Dr. Charles D. Meigs. We refer to the Alumen 
of the Pharmacopoeia. 

In an article published by Dr. Charles D. Meigs in the Medical Exam- 
iner (vol. i, p. 414, 1838), he says he has been " accustomed to make use 
of an emetic, which, so far as I can learn, is very little employed, but 
which, from the certainty and the speediness of its operation, ought to be 
more generally admitted into the list of available medicines for this par- 
ticular case at least. I have been familiar with its effects for more than 
twenty years, and my confidence in them increases rather than dimin- 
ishes by time." He adds, " I think that I have never given more than 
two doses without causing very full vomiting ; but I have often given 
large quantities of antimonial wine and ipecacuanha, without succeeding 
in exciting the efforts of the stomach." 

The alum is given in powder, in the dose of a teaspoonful, mixed in 
honey or syrup, or in syrup of ipecacuanha, to be repeated every ten or 
fifteen minutes until it operates. It is not generally necessary to give a 
second dose, as one operates in the majority of cases very soon after being 
taken. We have known it to fail to produce vomiting onty in two in- 
stances, both of which were fatal cases. In one the disease had gone so 
far before we were called, that no remedy had any effect upon the stomach. 
In the other, it was administered several times with full success, but lost 
its effect at last, as had happened also in regard to antimony and ipecac- 
uanha. The reasons for which we prefer alum to antimony, or ipecacu- 
anha alone, are the following: Antimony, when resorted to as frequently 
in the disease as we are of opinion that emetics ought to be, is too violent 
in its action; it prostrates many children to a dangerous degree, aud is, 
we fear, in some cases, itself one cause of death. It acts injuriously upon 
the gastro-intestinal mucous membrane when used in large quantities aud 
for any considerable length of time. Again, it is very apt to lose its 
effect, and to fail to produce sickness. Ipecacuanha is a much safer 
remedy than tartar emetic, but its operation is often too mild, and it not 
unfrequently fails to produce any effect after it has been used several 
times. The advantages of the alum are that it is certain and rapid in its 



100 PSEUDO -MEMBRANOUS LARYNGITIS. 

action, and that it operates without producing exhaustion or prostration 
beyond that which always follows the mere act of vomiting. It does not 
tend like antimony, and in a less degree ipecacuanha, to produce adyna- 
mia of the nervous system ; an effect which, in some constitutions or 
states of the constitution, or when it has been exhibited frequently, is 
often attended with injurious or even dangerous consequences. We have 
given alum in the dose above-mentioned every four or five hours, for two 
and three days, without observing any bad effects to result from it. The 
alum was given in all the cases that we have seen, in which emetics were 
'used, and was usually the only one employed when it was found to pro- 
duce full vomiting. In one of the cases accompanied by violent angina, 
ipecacuanha was substituted because of its smaller bulk. We have al- 
ready said that it failed to produce vomiting only in two instances. It 
was the emetic emploj'ecl in the nine cases in which fragments of false 
membrane were rejected, and in that in which the 3 T ellow viscid fibrin 
was expelled. Although it did not occasion the rejection of membrane 
in the other cases, it operated most speedily and efficiently. 

Sulphate of copper has been highly recommended by several writers for 
its emetic operation, and, by some of the German physicians, as exerting 
a specific influence upon the disease in addition to its emetic effect. As 
an emetic, it may be given to a child two or three j T ears old, in the dose 
of from half a grain to a grain every fifteen minutes, until it operates. 
To obtain its specific action it is continued afterwards in doses of a quar- 
ter of a grain eveiy two hours. 

We have also employed, with very good results, sulphate of zinc dis- 
solved in syrup of ipecacuanha, in the proportion of 2 or 4 grains to the 
fluidounce. Of this, a teaspoonful may be given to a child two or three 
years old, and repeated every fifteen minutes until it operates. This 
combination appears, like that of alum and ipecacuanha, to possess the 
double advantage of mild action without the production of any subsequent 
depression. 

We conclude these protracted remarks upon emetics with the statement, 
that from what we have read, and from personal experience, we are induced 
to regard them as the most important remedies we have to oppose to this 
fearful malady. The emetic, whatever it may be, ought to be given three 
or four times in the twenty-four hours, and in severe cases, once in every 
four or five hours. The exact periods, and frequency of the administra- 
tion, must be determined by the stage and urgency of the symptoms, and 
by the constitution and present strength of the patient. 

Mercury. — This powerful drug was first employed freely in the treat- 
ment of membranous croup by American physicians, and has subsequently 
been extensively used by English and European physicians. Calomel is 
the preparation almost always preferred, and many authors still recom- 
mend the administration of this remedy, in larger or smaller doses, in the 
earliest stage of the attack. 

Since the publication of the last edition of this work, our increased dis- 
like of the administration of mercury to children in large and frequently 
repeated doses, and the constant observation that even its free use does 



TREATMENT — LOCAL APPLICATIONS. 101 

not appear to arrest the course of true croup, or prevent the formation of 
membranous exudation, have led us to abandon entirety its employment 
in this disease. 

At the same time we believe there has been found, in the free adminis- 
tration of the alkalies, an agency far less injurious than mercury, and 
equally powerful, if not more so, in promoting the separation and dis- 
charge of the exudation, and preventing its reproduction. 

The internal remedies, then, upon which, after emetics, we rely most 
surely, are various alkaline salts, the use of which in large doses has 
been of late years highly recommended, both at home and abroad. 
Those which we are most in the habit of employing are the chlorate and 
citrate of potash, which should be given in full and frequently repeated 
doses, as, for example, two or three grains eve^ two hours to a child of 
four 3'ears old. We are also in the habit of combining with the chlorate 
of potash, tincture of the chloride of iron, in doses of three to five drops, 
at the same age. 

Antispasmodics are undoubtedly useful in some cases, when there is 
much laryngeal spasm. 

Opium is, however, the best remedy that can be employed for this 
condition, since it constitutes an important element in the treatment, by 
alleviating pain and restlessness, at the same time that it relieves the 
laryngismus, and thus diminishes the asphyctic symptoms. We would 
consequently recommend the use of some of the preparations of opium, 
as the tinct. opii deodorata, in such closes and at such intervals as will 
maintain a gentle opiate impression. In this, as in many other diseases 
of children, it is better not to prescribe the opium in combination with 
the other remedies that may be administered, but to either give it sepa- 
rately, or, better still, to add it to the dose of the other medicines at the 
time of administration, so that the amount of the dose of opium and the 
frequency of its repetition may be modified constantly in accordance 
with the condition of the child. 

Revulsives often prove useful in allaying restlessness, and moderating 
the violence of the suffocative attacks. Sinapisms and mustard poultices, 
applied upon various parts of the cutaneous surface, and mustard foot- 
baths, are amongst the best. The warm bath is often highly beneficial in 
the same way. 

We do not think it desirable ever to employ blisters in this disease. 

Local Treatment. — In those cases, and, as we have seen, they consti- 
tute the large majority of all cases of true croup, where the exudation 
appears in the fauces or on the tonsils before it imvolves the larynx, local 
applications to the throat are undoubtedly of importance. 

The objects of such applications are here, as in diphtheritic angina, 
to promote the separation of the false membrane, and to prevent its re- 
production. To fulfil the first of these indications, many authorities 
recommend astringent and caustic applications, which cause the pseudo- 
membrane to contract and shrink, and thus tend to promote irs separa- 
tion ; while others direct the use of those agents which exert a solvent 
action upon the exudation. 



102 PSEUDO-MEMBRANOUS LARYNGITIS. 

In the former class the most advisable are, alum ; tannic acid ; solutions 
of nitrate of silver; the astringent salts of iron, especially the tincture 
of the chloride and the perchloride ; dilute mineral acids and carbolic acid. 

Of these applications, those which we prefer are a solution of nitrate 
of silver, in the proportion of 5 to 20 grains to f^j of distilled water; 
and tincture of the chloride of iron, in the proportion of f3ss to fjij, to 
the f ^j of water. 

The second group comprises chiefly solutions of various salines, as the 
carbonate of potash, bicarbonate of soda, chlorate of potash ; and lime- 
water. 

If any of the astringent or caustic solutions are employed, we would 
recommend their application only to the patches of exudation in the 
fauces, since we regard it as highly doubtful whether they actually pos- 
sess the power of preventing the formation of membranous exudation 
when applied to the surrounding mucous membrane. Still more should 
we doubt the efficacy or advantage of introducing such solutions, and 
especially the more powerful ones, into the larynx ; either by pressing a 
soft sponge saturated with the solution upon the chink of the glottis, or 
by passing the sponge directly into the cavity of the larynx, as recom- 
mended by Dr. Horace Green. (Observ. on the Path, of Croup, &c, New 
York, 1852.) The practicability of this proceeding is undoubted, and a 
certain number of cases are on record, in which it seems to have been 
used with success ; but we have never resorted to the treatment ourselves. 

In cases occurring in older children, who can be induced to inhale the 
vapor from an atomizer or to allow a hand-ball atomizer to be used, the 
various astringent and solvent solutions above-mentioned can be applied 
most satisfactorily in this manner ; and, when this is practicable, we would 
prefer the use of lime-water or one of the alkaline solutions. 

In order to obtain the advantage which undoubtedly follows the inhala- 
tion merely of the watery vapor, we are in the habit of causing the child 
to inhale the vapor from slaking lime for a few minutes in every hour, by 
covering the patient's body with a thick cloth, and holding a vessel con- 
taining the slaking lime a short distance below his mouth under the cover- 
ing. It is doubtful, however, whether any appreciable amount of lime 
is carried up by the vapor so as to give the additional advantage of its 
solvent action upon the exudation. 

The reader is referred for more detailed discussion of this question of 
local applications in the treatment of croup, to the remarks upon treat- 
ment in the article on diphtheria. 

Hygienic Treatment — The child ought to be warmly clothed and 
confined to bed. The temperature of the room should be kept equable, 
and about 10° F. ; the air should also be frequently changed, so as to pre- 
serve it constantly pure and fresh. 

Owing to the loss of appetite and the pain caused by deglutition, it is 
often very difficult to induce the little patients to take food, so that this 
important element in the management of the case requires the utmost tact 
and attention. During the early part of the attack, the food should con- 
sist of light animal broths, beef tea, and preparations of milk. Later in 



SUMMARY OF TREATMENT — TRACHEOTOMY. 103 

the case, when the violence of the febrile action subsides, or if any symp- 
toms of exhaustion and prostration appear, a small amount of wine and 
water, of wine whe}~, or of weak milk punch, should be given. 

Ice, given in small pieces, to be held in the mouth, should be used very 
freely, as it relieves the parching thirst and at the same time appears to 
act favorably upon the inflamed mucous membrane. 

Summary of the Treatment. — The general plan of treating this dis- 
ease should, therefore, in our opinion, be somewhat as follows : The child 
should be confined strictly to bed. The food should be light, digestible, 
but nourishing, and, upon the earliest approach of exhaustion, a stimulus 
should be administered. In the early part of the attack, we should advise 
the use of revulsives, with mild counter-irritants ; topical applications to 
the fauces if there is any membranous exudation visible, and the internal 
administration of citrate of potash, with ipecac and small doses of opium, 
or of chlorate of potash with tr. ferri chloridi. So soon as the symptoms 
positively indicate the presence of false membrane in the larynx, we 
should resort to emetics, as directed in our remarks upon those remedies. 
And finally, after employing these means faithfully but without securing 
the discharge of the false membrane, while, on the other hand, the symp- 
toms of laiyngeal obstruction steadily progress, and the respiration grows 
more and more difficult, we must consider the propriety of resorting to 
the operation of tracheotomy, a proceeding which, as will be seen from 
the ensuing remarks, we approve of under the above circumstances. 

Tracheotomy. — The operation of tracheotomy would be apt to suggest 
itself to a medical man, on his witnessing the closing symptoms of croup, 
as the very means most likely to afford to the patient relief from the 
dreadful sufferings under which he labors, and as a possible rescue from 
impending death. It has accordingly been often resorted to in different 
parts of the world, at various stages of the disease, but with results that 
have led to very different conclusions. 

In England, for example, the operation was almost universally con- 
demned and abandoned about ten years ago ; and in the preceding edition 
of this work, we presented the unfavorable opinions of the most eminent 
English authorities. 

It was a matter of very great surprise, at that time, that the results of 
the operation in the hands of English surgeons should differ so widely 
from those obtained by the French physicians in similar cases. And, as 
there was no good ground for believing that sufficient difference existed 
between the croup of Paris and London, to explain the difference of suc- 
cess in the two cities, it is probable that the great disparity resulted, in 
part, from the operation being performed in France at an earlier stage of 
the disease, and in part also from the more careful after-treatment which 
the patients received. 

Within the past few years, however, the operation has been more favor- 
ably regarded by English surgeons, and the statistics published show that 
the proportion of success now obtained does not fall far short of that 
claimed by French operators. 

Thus in a paper read before the Royal Med. Chir. Soc, in 1857, by Dr. 



104 PSEUDO-MEMBRANOUS LARYNGITIS. 

Fuller, it is stated that up to that time 22 cases of tracheotomy in croup 
had been recorded in England, and that life had been saved in 8 of these, 
or in 1 out of eveiy 2| cases. 

In the statistical report of English Hospitals from 1854-59, it appears 
that the operation had been performed in 15 cases with 4 recoveries, or 1 
in every S| cases. Still further, from the statistics published by individual 
operators in England, since 1858, though it is not to be presumed that we 
have met with all the cases recorded, it appears that tracheotomy has been 
resorted to in 63 cases, with successful results in 24, showing a success 
of 1 in 2f . 

When it is borne in mind also, that in each of these instances the oper- 
ation was postponed to the last suffocative stage, and that, without ex- 
ception, the operators believe that the proportion of success would have 
been increased by its somewhat earlier performance, it becomes evident 
that tracheotomy has acquired a fair position in England among the 
legitimate operations of surgery. 

It is thus advocated bj Fergusson in the last edition of his Practical 
Surgery : and Dr. West, in 1859, speaks of it in these terms : " In spite 
of the unfavorable issue of the few cases in which I have either directed 
or sanctioned the performance of tracheotomy in croup, I am so far from 
being opposed to the operation, that my chief anxiety is to make out the 
indications which may justify me in having more timely recourse to it in 
future." 

In German}^, also, the operation, if not generally practised, is regarded 
as fully justifiable, and recommended and successfully performed by many 
of the most eminent authorities. 

The statistics of the results there obtained, borrowed from Fock 1 and 
Toss, 2 show that of 50 cases operated on in the last stage, 24 terminated 
favorably, giving a success of 1 in 2 T V, or 48 per cent. Steiner has also 
recently published (Jalirb.f. Kinderheilk., ]S T o. 1, 1868) the results of the 
operation in 52 cases (33 boj^s and 19 girls), which show a recovery of 18, 
or 34.6 per cent, of those operated upon ; and in an article upon diphtheria 
and tracheotomy by Giiterbock (Arch. d. Heilkunde, 1867, No. 6) 100 
cases operated on in Berlin are reported, with 33 cures. 

It is, however, in France that the operation first obtained, and has since 
firmly held, the position of a proper and legitimate method of treatment 
under certain circumstances of the disease. M. Bretonneau, of Tours, 
was the first who practised it with sufficient success in France to give it 
some vogue. Since that time, it has been recommended and performed 
by many different surgeons and physicians in that country, and particu- 
larly, as is well known, by M. Trousseau, who has been, undoubtedly, the 
most ardent and persevering, as well as the most experienced advocate of 
the operation. In one of his later publications upon this subject (Arch. 
Gen. de Med., Mars, 1855, p. 259), he thus boldly advocates it: "For 

1 Beport on Tracheotomy. Brit, and For. Med. Chir. Key., July, 1860, from 
Deutsche Klinik, I860. 

2 New York Journal of Medicine, January, 1860. 



TRACHEOTOMY — STATISTICS. 105 

my part, I am quite determined not to allow myself to be discouraged, 
but to preach tracheotomy with the greater conviction in proportion as 
its success increases, and did this proportion remain what it was ten years 
since. I should still proclaim the necessity of the operation, nor cease to 
say that it becomes a duty, a duty as imperative as the ligature of the 
carotid artery after a wound of that vessel, though death follows the 
operation as often, certainly, as recovery. 

M. Guersent {Diet, de Med., t. ix, p. 3*76) recommends the operation 
when the usual therapeutical methods have failed, "as the only means 
that offers a remaining chance." He adds (p. 311) that he is certain it 
does not add to the danger of the disease. MM. Rilliet and Barthez 
{Mai. des Enfants, 2eme ed., t. i, p. 331) say that, "The utility of trache- 
otomy in the treatment of croup cannot at this day be denied; numerous 
cases of children snatched from a certain and imminent death, reply vic- 
toriously to any doubts that ma}'' be raised as to the truth of this asser- 
tion." The authors of the Comp. de lied. Prat. (t. ii, p. 58*7) remark that 
of late years, "the successful operations have been numerous enough to 
dispel the unfortunate prejudices which tracheotomy has hitherto in- 
spired." M. Yalleix (Guide du Med. Prat., t. i, p. 388) says that the 
number of recoveries are "now too numerous to allow any one to think 
of opposing the operation except by statistics." MM. Hardy and Behier 
(Trait, de Path. Int., 1850, t. ii, p. 496) in speaking of the contest in 
regard to the propriety of the operation, say: "But the question seems 
now to be definitely settled ; the operation has succeeded in fact in a 
little more than one-fourth of the cases in which it has been performed, 
and, in presence of these results, it may be said to become the duty of 
the physician to have recourse to it, whenever, notwithstanding an ap- 
propriate treatment, the general and local symptoms indicate the exten- 
sion of the false membrane." 

M. Bouchut (Trait, des Mai. des Nouv.-nes, 2eme ed. p. 316) says, that 
when medical means have failed, and the disease has produced a "state 
tending towards asphyxia, in which an attack of suffocation might cause 
the death of the child, there should be no hesitation ; a new route must 
be artificially opened to the external air ; tracheotomy must be performed." 

At the time most of the above expressions were written, a compara- 
tively small number of operations had been placed upon record in France, 
but they were quite sufficiently numerous to show conclusive^ that, if the 
operation were carefully performed, and the after-treatment skilfully con- 
ducted, from 25 to 33 per cent, of the cases would recover. This excel- 
lent result is to be in great part attributed to the improvements introduced 
by Trousseau, and subsequently by other operators, both in the mode of 
performing the operation, and in the after-treatment of the cases. 

Since the publication of the last edition of this work the operation has 
continued to be so frequently performed in France, that we can not find 
space to quote the results obtained by individual operators. The aggre- 
gate of their reports, however, as collected b}^ Roger and See, Chaillou, 
Barthez, &c, yield a result of about one recoveiy in four in a series of 
over 500 cases. 

The proportion of recoveries has varied considerably in different years 



106 PSEUDO-MEMBRANOUS LARYNGITIS. 

in accordance with the type of the epidemic; in some years, as 1858, fall- 
ing as low as 1 in 6.9 (124 operations, and but 18 recoveries), while in 
other 3'ears it has risen even higher than 1 in 3. 

It is further to be remembered, that these French statistics are almost 
exclusively derived from the reports of the Hopital des Enfants, in Paris, 
and refer, therefore, to a poor class of patients, who have in many in- 
stances been subjected to improper and debilitating treatment before 
reaching the hospital, and who are exposed to unfavorable hygienic con- 
ditions while in the institution. When these unfavorable circumstances 
are allowed their full weight, it must be conceded that the operation of 
tracheotom} 1 " has achieved a considerable share of success in France, and 
has full}' justified the eloquent and enthusiastic advocacy of Trousseau. 

In America, tracheotomy has been resorted to but rarely until within 
the past few years. The statistics which have been lately published, 
however, fully suffice to show that, in the hands of American physicians, 
it has been very nearly, if not altogether, as successful as it has abroad. 
Dr. H. H. Smith (Oper. Surg., 2d eel., vol. i, p. 473) gives the results of 
26 operations performed in this country, of which 9 recovered. Dr. Gay 
(Boston Med. and Surg. Jour., Jan. 27, 1859, et al.) reports 13 operations, 
with 7 cures and 6 deaths ; and other operators in Boston have performed 
the operation in all 15 times, with 7 cures and 8 deaths. But by far the 
most extensive statistics have recently been published by Dr. A. Jacobi, 
of New York (Amer. Jour, of ObsteL, May, 1868, pp. 13 to 65), derived 
exclusively from the practice of physicians in that city. 

The following table shows the results obtained : 

Operator. No. of cases. 

Jacobi, . . . 67 

L. Yoss, .... 43 . 

E. Krackowizer, 55 

W. Yon Both, ... 48 . 

Total, . . 213 50 23£ 

In this city the operation has been as jet but seldom resorted to, and 
with but moderate success, owing to the fact, that in nearly every instance 
it has been postponed until the child was almost moribund. The follow- 
ing table embraces certainly the great majority of the operations that 
have been performed ; for a knowledge of which we are to a great extent 
indebted to the courtesy of the operators, since but few of them have as 
yet been placed on record : 



. of cures. 


Percentage of 




success. 


13 


19* 


10 


. 231 


16 


29 


11 


23 



Name of operator. 


Number of cases. 


Number of cures. 


Physick, . 


2 





Goddard, 


2 





Page, 


1 





J. Pancoast, 


6 


3 


R. J. Levis, . 


. 11 


1 


T. H. Bache, . 


1 





A. Hewson, 


1 





H. Lenox Hodge, 


3 


2 


J. H. Packard, 


1 





Total, 


. 28 


6 or 21. 



6 or 21.4 per cent. 



TRACHEOTOMY — ESTIMATION OF ITS VALUE. 107 

Finally, to sum up the statistics given above, although even this aggre- 
gate does not include by any means all recorded cases, Jacobi states (loc. 
c#.), that out of 1024 operations of tracheotomy, performed in various 
parts of the world, but principally in Europe, 220 or 21.48 per cent, re- 
covered. 

It is evident, therefore, that wherever this operation has been practised 
in true croup, a considerable proportion of cures has been effected ; but 
in order to form a clear opinion as to the real merits of the operation, it 
is necessary to have some idea as to the number of subjects that might 
have recovered without a resort to it. 

This is very easily arrived at in this country, since we believe that it 
is never performed here except as a last resort, when the patient is mani- 
festly in great danger of death, or absolutely moribund. 

In regard to the French operations, it is not so clear whether some of 
the patients, who recovered after the operation, might not have been so 
fortunate without it, particularly as M. Trousseau formerly recommended 
that it should be performed so soon as we can be certain that the larynx 
contains false membranes. But then it is generally understood that he 
was not called to many of the cases upon which he operated until all 
other means had failed, and the child had fallen into an apparently hope- 
less condition. To elucidate this matter, we shall quote the statements 
made by M. Talleix, one of the most accurate and impartial of writers. 
M. Talleix (loc. cit., p. 388-9) tells us that he collected together 54 cases 
of undeniable, well-marked true croup, treated without the operation, and 
found that It had been cured. Then, examining what had occurred in 
regard to the operation, he found, as M. Bricheteau had done before, that 
nearly 1 in 3 had recovered, a success almost precisely the same as had 
taken place in the cases treated by medical means alone. "But," he goes 
on to remark, " there is a consideration of very great importance, one 
which gives an altogether different value to tracheotomy, to wit, that in 
the immense majority of instances, the operation was performed under 
the most discouraging circumstances, and only when all other methods 
of treatment had proved useless, and the severity of the symptoms, and 

the near approach of asphyxia, indicated impending death So 

that it follows that tracheotomy should be regarded, in connection with 
croup, as a genuine medical victory, the honor of which belongs to M. 
Bretonneau, and all preconceived views should fall before the actual 
facts." We have here the evidence of a most competent witness, living 
on the spot, to convince us that the operation is not resorted to in France, 
at least generally, early in the disease, but is performed only as a last 
resource, when the chance for the patient from the efforts of nature, or 
from medical means, is almost null. How, then, can we resist the con- 
viction that tracheotomy does afford a sufficient probability of success, 
after other means have failed and death is fast approaching, to render a 
recourse to it at least justifiable, if not almost compulsory ? 

The second point to be examined in discussing the propriety of the 
operation is, whether it be in itself dangerous. 

From the opinions expressed by authors upon this subject, it appears 



108 PSEUDO-MEMBRANOUS LARYNGITIS. 

that the only serious danger attendant upon the operation is the occur- 
rence of hemorrhage. When performed for the removal of foreign bodies 
from the air-passages, the patients almost always recover if the foreign 
body do but escape. M. Ollivier (Art. Larynx, Corps Etrangers, Diet, 
de Med.) sa} T s that the success of the operation is, so to speak, certain, 
when it is performed carry. Liston disapproves of the operation in croup, 
but states that it is not attended with much danger. Skey regards it as 
an operation of some difficulty and clanger, from the irregularity in the 
distribution of the vessels, and the existence of numerous veins which 
ma} r bleed profusely. M. Boyer does not regard it as dangerous, and 
states that the only danger is from the occurrence of venous hemorrhage 
into the trachea, and not from the amount of blood lost. Chelius says 
that it is dangerous below the cricoid cartilage from anastomosis of the 
thyroidean arteries, from the presence of venous plexuses, and sometimes 
from a deep thyroidean artery. Yelpeau speaks of the venous hemor- 
rhage as alone dangerous. Trousseau states that he has performed it 
more than 200 times, and has met with but a single fatal accident in all 
of these. Dr. Pancoast, of this city, who has operated in more than 6 
cases of croup, and a number of times for the removal of foreign bodies 
in the air-passages, has never met with any serious difficulty in the per- 
formance of the operation, nor with any accident which he could suppose 
might have affected the life of the patient. Dr. H. H. Smith {op. eit., p. 
4^4), when commenting upon the great disparity of the mortality after 
tracheotomy, when performed for removal of foreign bodies, and when 
for the relief of croup, remarks that it is very evident that the dangers 
which ensue upon incising a healthy trachea are comparatively slight, and 
that the great mortality which has attended the operation when performed 
for the relief of croup, must be due to some other cause than the mere 
incision of the windpipe. 

If, then, it is the uniform testinunry of those experienced in the matter 
that the operation is in itself alone but slightly dangerous to life, so that 
its performance adds but little to the danger of the patient ; if it affords 
immediate relief to the suffocation which threatens to be soon fatal, and 
at least gives additional time, during which the gravity of the disease 
may subside ; if, further, as we think has been most conclusively shown 
by the statistics quoted, it has unquestionably saved the lives of a con- 
siderable number of those upon whom it has been performed, it is diffi- 
cult to avoid the conclusion that it is our imperative duty to resort to the 
operation under certain circumstances. 

That some who have been operated upon might have recovered without 
it, is highly probable ; but the uncertainty as to the absolute necessity of 
resorting to it in any individual case is not even so great, probably, as 
that which exists in regard to many other surgical operations, and to 
many medical applications. 

Our own plan, then, is to try faithfully all medical means ; and, being 
satisfied of their powerlessness and of the certainty of a fatal issue to 
the case without the performance of tracheotomy, to inform the parents 
of the inability of mere medical means to afford relief, and to propose the 



TRACHEOTOMY — PERIOD FOR OPERATING. 109 

operation to them, setting before them the great probability of its not 
averting death, bnt still strongly pointing out the fact that it does not 
add to the danger of the case, but gives so much additional chance for 
life that about 1 in every 4 operated upon recovers. 

Should they throw the whole responsibility upon us, we should, with- 
out hesitation, advise the operation. Our grounds for so doing are very 
simple, and have been before indicated. The operation does assuredly 
frequently save life. It is not in itself attended with any great danger. 
It cannot increase the danger of the patient's position, but certainly gives 
an additional chance of escape from the disease ; and, lastly, it mitigates, 
in a remarkable manner, the sufferings of the patient. On several occa- 
sions, indeed, we have been told b} T the parents, after the death of their 
child, that they were very glad it had been performed, since, at all events, 
it had removed the frightful gaspings and stragglings for breath which 
had previously convulsed the whole frame of the poor little sufferer, and 
had rendered his last hours easy and tranquil. 

If we decide that tracheotomy is justifiable, it becomes all-important 
to determine the period of the disease at which we should have recourse 
to it, 

M. Trousseau formerly laid down the rule that it was to be performed 
so soon as it was certain that false membranes had formed in the larynx. 
He fixed upon this as the proper moment, because he believed that death 
was, under these circumstances, almost inevitable. 

This opinion is, however, readily proved to be untenable. We have 
already learned from M. Yalleix that of 54 perfectly well-marked cases 
collected by himself, treated medically (without the operation), IT, or 
about a third, recovered. If we add to this that, of 35 cases seen by our- 
selves, 15 recovered without the operation, it becomes very clear that the 
mere presence of the exudation in the larynx is not sufficient warrant for 
a resort to the operation. 

According^, most authorities advise that we should wait until medical 
means have been fairly tried. Thus, MM. Rilliet and Barthez (pp. cit., 
t. i, p. 340), in discussing the period at which the operation ought to 
be performed, conclude that it should not be resorted to until the means 
that have succeeded in other cases have been fairly tried, and it has be- 
come evident that they must fail. The}^ advise the practitioner not to 
wait, however, too long a time, but to operate even early should the pa- 
tient suffer a paroxysm of suffocation so severe as to make it probable 
that another might prove fatal. So, too, Mr. James Spence, in a valu- 
able paper on tracheotomy {Edin. Med. Jour., Feb., 1860), states, as the 
result of his large experience, " that if, in a case of croup, all measures 
have been actively tried, if the hard, ringing cough has become sup- 
pressed, and the respiration is evidently imperfect, as shown by the con- 
tracted and depressed appearance of the cartilages of the ribs, and the 
occasional severe paroxysms of dyspnoea, the operation is fully warranted. 
When the parox3^sms become more and more frequent, and when the 
dyspnoea is rather persistent than parox}^smal, with turgid or pale lividit y. 
the operation is the little sufferer's only chance for life." 



110 PSEUDO-MEMBRANOUS LARYNGITIS. 

This same course is, we believe, universally pursued in this country, 
and, as the reader will recollect, corresponds precisely with the advice 
given in our remarks on the medical treatment of true croup. 

The prime indication for the performance of the operation is, then, the 
degree of laryngeal obstruction as shown by the characters of the respi- 
ration, the cry, and cough. 

It should, however, be carefully borne in mind that great dyspnoea, or 
even asphyxia, when intermitting, do not so imperatively claim operative 
interference, since cases where the dyspnoea is of this character ma}' re- 
cover without the operation. 

When, however, despite the use of all medical means, and especially 
the repeated administration of emetics, the dyspnoea grows steadily and 
progressively greater; w 7 hen there is marked hissing laryngeal stridor, 
and, at each inspiratory effort, recession of the base of the thorax; when, 
in addition, the voice is whispering or suppressed, and the cough short, 
smothered, and muffled, the operation should, we think, be unhesitatingly 
performed. 

In thus defining the conditions under which tracheotonry is called for 
in croup, it is clear that we are not to be influenced at all by the mere 
period of the disease as measured by time, but that, whenever the above 
symptoms are present, the operation is indicated. 

There can be no doubt, however, of the far greater success of the opera- 
tion when performed in the early period of the attack, before the patient's 
strength is materially impaired ; and it is, therefore, highly desirable that 
the indications which render its performance necessary should be appre- 
ciated so soon as the} r appear. 

Thus Trousseau, in his last publication upon this subject {Clin. Med., 
2eme ed., t. i, p. 450) speaks as follows : "I wrote in 1834, and repeated 
in 1851 : so long as tracheotomy was not a trusty weapon in nry hands, 
I said : we should operate as late as possible ; but now that I can number 
many successes, I say, we should operate as early as possible. In re- 
moving from this assertion whatever may seem too absolute, I still affirm 
it, by saying, that the chances of the success of the operation are so much 
the greater in proportion as it has been the earlier performed." 

Notwithstanding this, however, should we be called to a case where 
the last stage of asplryxia has been reached, it is still not too late to per- 
form the operation. Thus, in one of the cases that occurred in our own 
practice and which ended favorably, this condition was fully developed, 
and the bluish skin, drowsiness and insensibility to pain, showed that 
the patient had already sunk into very advanced asphyxia. 

Perhaps we cannot do better in closing our remarks upon this point, 
than to quote the concise and forcible axiom laid clown by Archambault : 
" We should never operate too late : it is never too late to operate, so 
long as death is not actually present." 

There are, however, certain conditions which have been thought by 
many authorities to contraindicate the performance of the operation even 
under the circumstances above described. The first of these is the very 
early age of the patient, and it has been advised to refuse the operation in 



TRACHEOTOMY — CONTRAINDICATIONS. 



Ill 



all cases occurring under the age of two years. It is unquestionably true, 
as might be expected, that age exercises a most powerful influence upon 
the prognosis after the operation, owing partly to the difficulty in per- 
forming it on account of the narrowness of the trachea and the shortness of 
the neck, but chiefly to the deficienc}^ of vital power, and to the difficulty 
of nourishing the infant afterwards. Notwithstanding these influences 
which render the prognosis so unfavorable in tracheoton^ before the age 
of two years, there are so many successful cases on record that the most 
tender age can no longer be regarded as a positive contraindication. 
The following list embraces the names of the operators and the age of 
the infants in the cases which have been successful at a very early age : 



Baizeau, . 


. at 


10 


months. 


Vigla, 


at 


17 months 


(i 


. " 


15 


t< 


Potain, 


a 


18 


« 


" (in hands 


of his 






Moutard-Martin, . 


a 


18 


<( 


colleag 


ue), " 


15 


a 


Trousseau, 


Ct 


13 


« 


Isambert, 


ct 


16 


(< 


Barthez, . 


et 


13 


(< 


Archambault, . 


u 


13 


(( 


u 


u 


7 


a 


(( 


ti 


18 


a 


Maslieurat Lagemand 


u 


23 


u 


Roger ; 


a 


19 


a 











In adults, on the other hand, tracheotomy in croup is less successful 
than in children, probably because, as Trousseau suggests, the form and 
size of the larynx allows the pseudo-membrane to extend deeply into the 
bronchia before producing the symptoms of croup. 

There is another condition which, it is thought by many, ought to 
constitute an insuperable bar to the operation, and the possible existence 
of which, in airy case, is one of the most serious objections that has been 
brought against its performance. The condition to which we allude is 
the presence of pseudo-membranous exudation in the bronchia. 

The existence of this condition must greatly lessen the chances of a 
successful operation, but that it renders success impossible, as has been 
supposed, cannot be admitted. MM. Rilliet and Barthez (op. cit., 2eme 
eel., t. i, p. 338) says : " It has been said that one contraindication was 
the presence of false membrane in the bronchia. But, besides the fact 
that the symptoms denoting its presence are uncertain, we cannot see in 
this a positive objection to the operation. Recovery has been known to 
occur, in effect, after the rejection of bronchial false membranes, and we 
were ourselves witnesses of a remarkable example of this kind. And is 
there any better mode of facilitating the escape of foreign bodies than by 
opening to them a passage below the larynx? Under such circum- 
stances, we must expect, to be sure, a greater mortality than under more 
favorable conditions. This opinion is, moreover, that of M. Bretoimeau." 
Numerous cases are indeed on record, and we have ourselves met with 
such, where, after the operation, large membranous casts of the trachea 
and bronchia, which could certainly never have escaped through the 
larynx, have been discharged through the tracheal opening, and their 
escape followed by complete recovery. 



112 PSEUDO-MEMBRANOUS LARYNGITIS. 

It appears evident, therefore, that if in such cases, when death is even 
more surely imminent than in those instances when the exudation does 
not extend below the larynx, tracheotomy affords even a very slight ad- 
ditional chance of recovery, it should be performed despite the fact that 
the child will in all probability die. 

But apart from this consideration, it must be borne in mind that sta- 
tistics prove that the false membrane extends below the larynx in about 
one-third of all cases, and still further, that there are no means by which 
we can with certainty determine in any individual case whether such ex- 
tension has taken place or not. 

It was at one time thought that auscultation might afford the desired 
information, but more careful observation has shown that it is not to be 
depended upon. As already said, in most cases the laryngeal stridor is 
so loud as to mask all chest-sounds, and, even when this does not hap- 
pen, we have frequently observed that no definite and reliable informa- 
tion is to be gained from physical examination. The following cases 
may be quoted, out of the number on record, besides several that we 
have ourselves seen, as proving this statement. MM. De La Berge and 
Monneret (Comp. de Med. Prat., t. ii, p. 587), mention a case in which 
they could not believe that the bronchia contained false membranes, as 
the vesicular murmur was extremely pure and was heard everywhere; 
and yet, during the operation, a false membrane was drawn out, which 
represented the trachea and the division of the principal bronchia. The 
child died in 15 hours. 

The late Prof. William Pepper, of this chVy, reported 2 fatal cases {Sum- 
mary of Trans. Coll. Phys., vol. iii, No. iii, p. 106) in one of which "dis- 
tinct vesicular murmur could be heard throughout the lungs, marked 
only occasionally by sibilant and sonorous rales," a few hours before tra- 
cheotomy was performed. The child died 20 hours after the operation, 
and the exudation was found to implicate the larynx, trachea, the large 
bronchia, and even some of the smaller ramifications. In the other case, 
the state of the respiration was carefully examined the clay before death, 
and not the least respiratory murmur could be heard over any part of the 
chest, and yet in this instance, the exudation was confined strictly to the 
larynx ; not a vestige of false membrane was to be found either in the 
trachea or bronchia. 

In a case recently attended by us, where tracheotomy had been per- 
formed, so that all laryngeal stridor was absent, auscultation, eight hours 
before death, revealed quite strong respiratory murmur, much obscured 
by snoring bronchial rales. The antero-lateral parts of the chest were 
alone ausculted. Death occurred somewhat suddenly from the lodgement 
of a very large tubular membrane from the left bronchus in the trachea: 
and at the autopsy there was a tubular membrane found extending 
throughout the trachea, and through the right bronchus to its third di- 
visions. The left lung was collapsed and congested ; the right one dis- 
tended and emphysematous. 

Since, then, we can learn little or nothing from auscultation or any 
other means, as to the presence of false membrane in the bronchia, the 



TRACHEOTOMY — CONTRAINDICATIONS. 113 

question becomes one of expediency, so far as this contraindication is 
concerned, whether to leave two-thirds of the patients, mairy of whom 
could certainly be saved by the operation, to perish without an effort to 
save them, because one-third must probably die ; or to perform the opera- 
tion, with veiy little prospect of success in one-third, for the sake of the 
chance of saving many of the remaining two-thirds who must otherwise 
perish. 

The presence of pneumonia is also universally recognized as greatly 
lessening the chances of recovery after tracheotomy. It must be borne 
in mind, in regard to this point, that pneumonia is frequently overlooked, 
and indeed that it frequently cannot be recognized on account of the loud 
tracheal rales which hide all auscultatory sounds : while, on the other hand, 
its presence may be simulated h\ the occurrence of collapse of some por- 
tion of the lung, owing to occlusion of the bronchus leading to it. Mil- 
lard suggests that the degree of ctyspnoea may be of service as indicating 
the presence or absence of pneumonic complication. Thus he has found 
that in croup not thus complicated, the rate of respiration is from 32 to 
48, while when pneumonia is present, it rises above 50. Pneumonia of 
one lung is not, according to Guersent, a contraindication, nor is even 
double pneumonia regarded by some operators as absolutely interdicting 
the operation, though at the same time we are not aware of a single in- 
stance in which it has been successfully performed where this condition 
was unquestionably present. 

Another condition in which tracheotomy is thought by many to be 
contraindicated, is when membranous croup occurs as a secondary affec- 
tion, during the course of some constitutional disease other than diph- 
theria, as for instance, scarlatina, measles, or pertussis. Such cases were 
regarded even by Trousseau, as absolutely unfit for operative treatment. 
Still, that this contraindication, although of the greatest weight, does 
not entirely forbid tracheotomy, is shown by a case of croup following 
scarlatina, in which Dr. Yoss operated, and the child survived 31 (lays, 
the tracheal wound being nearly closed. Millard also, in his excellent 
essay on tracheotomy (De la Tracheotomie dans le Gas de Croup, Paris, 
1858), records 3 cases of croup secondary to measles, successfully treated 
by operation. He regards croup occurring in the course of pertussis as 
far less unfavorable, since the violent cough favors the expectoration of 
the false membranes. 

There remains, finally, one condition to be indicated in which the 
operation is, in the almost unanimous opinion of authorities upon this 
question, absolutely contraindicated. We refer to the cases of profound 
general diphtheritic infection, where the danger of the child depends upon 
the constitutional disease, even more than upon the laryngeal obstruc- 
tion, where the blood is gravely altered, and the well-known tendency 
exists to the formation of pseudo-membranes upon all abrasions or wounds, 
so that in all probability the operation would merely serve to invite the 
extension of the exudation. 

Trousseau opposes the operation under such conditions, in the following 
words : "If the diphtheritic infection have profoundly attacked the eon- 



114 PSEUDO -MEMBRANOUS LARYNGITIS. 

stitution, if the skin, and especially the nasal passages are occupied by 
the specific inflammation, if a frequent pulse, delirium, and prostration 
show the system to be deeply poisoned, and if the danger is rather from 
the general condition than from the local lesion of the larynx and trachea. 
the operation ought never to be attempted, for it is invariably followed by 
death." 

Even under this most unfavorable of all conditions, however, there are 
not wanting some operators of wide experience, who still recommend the 
operation: thus Jacobi (loc. tit.) asserts, that whenever the indication 
of suffocative dyspnoea, steadily increasing and not relieved by emetics, 
exists, he would operate despite any complications, general diphtheria, 
or anything else, and uses this powerful language : " Seeing a person 
suspended by the neck and being strangled, we should hardly investigate 
the propriety of cutting the rope from the point of view that the sufferer 
might be or is affected at the same time with tuberculosis, cancer, or 
diabetes." 

After a careful review of the entire question, we believe that the facts 
upon record justify the following conclusions: that the condition of suc- 
cess which excels all others is the predominance of the characters of 
asphyxia ; that when these are so marked that death is imminent, the 
operation is justifiable despite any complications which ma} r coexist, save 
perhaps the presence of grave general diphtheritic infection ; and finally 
that, when no such contraindication is present, and the dyspnoea is con- 
tinuous and increasing despite all other treatment, the operation is posi- 
tively indicated, and it becomes the duty of the practitioner to recom- 
mend its performance, and, if the decision be intrusted to him, to un- 
hesitatingly assume the responsibility of operating. 

We have already indicated with sufficient clearness the influence which 
the age of the patient, the period of the disease, and the character of the 
epidemic exert upon the results of tracheotomy. But we would again 
allude to the marked manner in which the result is modified by the 
character of the previous treatment, and to the fact that its success is 
very much interfered with by the earlier employment of any debilitating 
measures, such as were, until lately, but too frequently adopted. 

We have more than once been asked by the parents of children, upon 
whom tracheotomy was about to be performed, or who had actually un- 
dergone it, what influence would be exerted by the effects of the opera- 
tion, should it be successful, upon a subsequent attack of croup ; and 
since, as has already been seen from the cases quoted by us from our 
own experience, second attacks of croup are not very rare, it is interest- 
ing to know, that so far the statistics which bear upon this question tend 
to show that a previous attack of croup cured by tracheotomy is a favor- 
able condition for its performance in a subsequent attack. Thus of 5 
cases, collected by Millard, in which the operation was performed for the 
second time, every one recovered. The second operation was uniformly 
found much easier, on account of the cicatrix of the former incision 
serving as a guide, and also on account of the slight amount of the hem- 
orrhage. 



TRACHEOTOMY — MODE OF PERFORMING THE OPERATION. 115 

Mope of Performing the Operation. — Tracheotomy being an opera- 
tion which all physicians, whether experienced or not in the use of surgi- 
cal instruments, are liable to be called upon to perform at a moment's 
notice, no apology is needed for the introduction here of the details of its 
performance. The following account is in great part borrowed from the 
pages of that most experienced tracheotomist, Trousseau, 1 and from a 
very complete and practical discussion of the operation by F. Howard 
Marsh. Esq. 2 

The child should be carefully wrapped up, so as to avoid all exposure 
to cold; and if an anaesthetic is to be employed, should be allowed to sit 
or lie in an}' position he may choose during its administration, as the 
constrained position necessary during the operation tends to increase the 
difficulty of breathing. He should then be placed upon a table, furnished 
with a thin mattress, and a folded pillow or roll of cloth should be placed 
under the shoulders and back of the neck, so as to put the skin of the 
throat upon the stretch, and render the trachea prominent. If the ope- 
ration is performed during the day, the table should be drawn close to the 
window, and the patient's face directed toward it, so that a full light may 
fall upon the throat ; if, however, it be at night, a special assistant must 
be intrusted with the duty of holding the candles or lamp. An assistant 
is also needed to stand behind the patient and hold the head securely; 
and another, whose duty shall be to draw aside the successive layers of 
tissue and the bloodvessels with a hook, and to sponge the wound from 
time to time. 

The instruments needed are a sharp-pointed, slightly curved bistoury; 
a blunt-pointed bistoury ; two flexible hooks ; a dilator to stretch the in- 
cision in the trachea so as to favor the introduction of the canula, and 
made like a pair of curved dressing forceps, with a little spur projecting 
backward, so as to catch in the tissues and prevent its displacement; 
and finally a canula. The size and form of this canula are matters of 
great importance; and of late years several marked improvements have 
been effected in them. The calibre of the canula should, as first clearly 
directed by Trousseau, be as large as possible without interfering with its 
easy introduction into the trachea, and its curve should be that of a 
quarter of a circle. 

In regard to this very important question of the size of the canula, we 
are indebted to Mr. Marsh {loc. cit.) for a series of observations, which 
appear to indicate that a tube somewhat smaller than that recommended 
by Trousseau, Fuller, and others, may be equally efficient and yet less 
irritating. By a series of careful measurements of the respective diame- 
ters of the trachea and cricoid cartilage, he established the fact that the 
latter diameter is almost invariably less than that of the trachea, to an 
extent varying from ^th to /oths °f an ^ ncn - *A therefore, as his meas- 
urements show, the diameters of the trachea are as follows: during the 
first two years of life, jgths of an inch ; in the third year, Jjths ; in the 

1 Clin. Med., 2 erne ed., torn, i, p. 414 et seq. 

2 St. Barth. Hosp. Kep., vol. hi, p. 331 et seq. 



116 PSEUDO-MEMBRANOUS LARYNGITIS. 

fourth and to the seventh, Jgths ; in the eighth and ninth, Jgths ; and in 
the tenth, Jgths ; it will be seen that a canula having a diameter of ? 9 ths 
of an inch will answer for children between the ages of 1 and 4 years ; 
one of ^ths for children between 5 and 8 years ; and one of f'gths for 
children between 9 and 12 years old. 

It may be added that after the 12th year the diameters of the cricoid 
cartilage and trachea increase so rapidly, that the canula now usually 
made for adults, with a diameter of ^-Jths of an inch, is rather small for 
children between 11 and 16 years old. 

The length of the canula should be sufficient to cause it to reach from 
■J to 1 inch below the inferior angle of the wound in the trachea. 

The canula must also be double, the outer tube having a broad collar 
in front, with holes through which the band which passes around the neck 
and secures the canula in position, may be passed and tied. It should 
also be furnished with a key, which pla} T s easily in a notch on the upper 
part of the inner tube. This inner tube must so fit the larger one, as to 
be readily removed and replaced, being secured in position by the little 
key above-mentioned. 

In some canulas a still further improvement is introduced, by having 
the outer tube and collar merely yoked together by means of two arches 
on the collar, which receive small outjutting bars at the sides of the upper 
extremity of the outer tube, so that this can shift its position according to 
any pressure it may receive. 

There is also a canula recommended by Fuller, called the "bivalve 
canula," the outer portion of which is not a tube, but consists of two nar- 
row lateral blades, which are easily compressd by the finger and thumb 
into the form of a thin wedge, and expand again when the pressure is 
removed. This instrument supersedes the need of any dilator, and has 
the great advantage of being readily introduced. It is evident, however, 
that it must produce much more irritation while in position, than a tubu- 
lar canula. and in addition, when the inner tube has been removed, as is 
frequently required, its reintroduction causes pain and irritation, from the 
constriction of the mucous membrane which has bulged inward between 
the blades of the outer portion. Mr. Marsh, therefore, advises that when 
there is any difficult}' in introducing the canula at the time of the opera- 
tion, a Fuller's tube should be used, but that this should be exchanged 
on the second day for one whose outer portion is tubular. 

Although it is almost the universal practice to introduce a canula at 
the time of operation, its use has been objected to by several good authori- 
ties, as apt to cause inflammation and ulceration of the trachea, and to 
favor the development of pulmonary complications ; and several plans 
have been suggested for the separation of the edges of the tracheal wound. 
Thus Mr. Adams, of the London Hospital, recommends the introduction 
of a strong metallic wire speculum, such as are frequently used in opera- 
tions on the eyes, and Dr. Pancoast, of this city, employs a pair of blunt 
leaden hooks. 

In addition to the instruments already enumerated, some operators, fol- 
lowing the practice of the Dublin surgeons, use a hook or tenaculum to fix 



TRACHEOTOMY — MODE OF PERFORMING THE OPERATION. 117 

the trachea, while the incision is being made through its rings. This pro- 
ceeding has certain advantages, especially when it is designed to excise 
a portion of the trachea, or in case of venous hemorrhage, as the trachea 
can be raised above the pool of effused blood and speedily opened, which 
will usually check the bleeding. It is also of service in young children, 
because the trachea is then so pliable and yielding, that, unless the hook 
be used, its anterior wall may be easily driven in front of the point of the 
scalpel, till it is nearly or quite in contact with the posterior, in which 
case the latter also may be wounded. Trousseau, Millard, and others, 
however, strongly object to this practice, believing it to be dangerous to 
so fix the trachea and oppose the movements connected with the perform- 
ance of the function of respiration which is already so much impaired. 
Our own observation would go to show that, while the advantages to be 
gained from fixing the trachea are undoubted, especially in young chil- 
dren, the dangers have been somewhat exaggerated. 

It has been recommended by several high authorities — Lawrence, Car- 
michael, G. H. Porter, Brainard, Fergusson — to excise a small piece of 
the walls of the trachea. By some this has been adopted with the view 
of dispensing with the use of a canula, but it is claimed that, even when 
one is einploj'ed, this practice renders its introduction more easy ; that 
the tube fits the oval opening thus made much more accurately than a 
mere slit, produces less pressure upon the edges, and consequently is not 
so apt to produce caries of the tracheal rings. It seems never to be fol- 
lowed by narrowing of the trachea after the canula has been removed, as 
might be apprehended. 

This practice is followed by Dr. Pancoast of this city, who, in the case 
he describes, excised an elliptical piece about one-third of an inch long 
and two-tenths of an inch broad, from the front part of the third, fourth, 
and fifth rings of the trachea. As already said, he does not employ either 
a canula or dilator, but holds apart the edges of the wound made in the 
soft parts over the trachea by means of a piece of thick leaden wire, bent 
so as to form hooks at either end. The wire is of such a length as to fit 
accurately around the neck when the hooked ends are placed within the 
edges of the incision, and thus keeps up just sufficient traction in oppo- 
site directions to maintain the wound open. 

In regard to the operation itself, almost all who have had much expe- 
rience in it direct that it must be performed with great deliberation and 
care. 

The incision through the skin should be made precisely in the median 
line of the neck, and should extend from the cricoid cartilage to a little 
above the sternum. The slight white fibrous line which marks the inter- 
space between the sterno-hyoid and sterno-thyroid muscles should then 
be followed as a guide for the next incision, and the muscular masses 
drawn aside by hooks. 

The trachea is now exposed with the isthmus of the thyroid gland and, 
occasionally, large thyroidean veins lying upon it, and great care must be 
observed to avoid wounding these on account of the troublesome hemor- 
rhage which is apt to follow. A still further reason for this caution is the 



118 PSEUDO-MEMBRANOUS LARYNGITIS. 

occasional existence of an anomalous distribution of arteries, by which 
a branch of considerable size, or even the innominate artery itself, passes 
over the trachea directly in the course of the wound. Any bloodvessels 
may be drawn aside b} r hooks, and the isthmus of the thyroid gland may 
either be treated in the same way, or, if it cannot be drawn away far 
enough to allow a sufficient incision of the trachea, may be ligated in 
two places and divided between (Brainard, of Chicago), although, when 
possible, this had better be avoided. The trachea, having been thus care- 
fully exposed, should be punctured just below the cricoid cartilage, and 
the probe-pointed bistoury being introduced and its edge guarded by the 
nail of the index finger of the left hand, the opening should be enlarged 
downwards to the extent of two or three tracheal rings. 

It usually occurs that there is some hemorrhage during these incisions ; 
but if it be venous and moderate in amount, the opening of the trachea 
should not be deferred, as the re-establishment of respiration will usually 
speedily check it. 

So soon as the trachea is incised, the dilator should be instantly intro- 
duced with the blades closed ; and so soon as in position these should be 
moderately opened. Air now enters readily, and there is a discharge of 
mucus, fragments of false membrane, and blood, through the opening. 
The canula should then be introduced upon the dilator as a guide, its en- 
trance being evinced by the increased facility of respiration, and the 
escape of mucus and blood through its calibre. A guard of india-rubber 
or a disc of waxed cloth should then be placed between the guard of the 
external tube and the skin, to prevent any irritation or chafing, and the 
canula may be fastened in position b}^ a tape passed around the neck. 

Should blood bubble up by the side of the canula, as Geraldes observes, 
the wound in the trachea has been made too large, so that the blood gains 
entrance during inspiration, and a larger canula should be at once sub- 
stituted. 

It occasionally happens, as in a case related by Trousseau, that the 
trachea is lined by a false membrane, which is partly detached and pressed 
forward by the end of the canula, so that it completely occludes the open- 
ing, and thus even increases the asphyxia. When this occurs, the canula 
should be withdrawn, and an attempt made to seize the false membrane 
with forceps and withdraw it. 

When the operation has been a laborious one, emplrysema of the neck 
may be met with, sometimes extending to a considerable distance, and 
causing great disfigurement or even seriously complicating the course of 
the case. It results from a want of parallelism between the cutaneous 
and tracheal wounds, or from marked disproportion between the size of 
the tracheal wound and that of the canula, or, as occasionally may happen, 
from the escape of the canula from the tracheal wound. It has also hap- 
pened that the inflamed and thickened mucous membrane is stretched 
over and driven before the point of the scalpel, and so escapes a sufficient 
division. 

It has not been customary to use anaesthetics in the performance of 
tracheotomy. Fock, however, adA'ises the use of chloroform, and states 



AFTER-TREATMENT. 119 

that he has never, even in extreme dyspnoea, found an}^ ill effects to re- 
sult from its einphrpnent. At first the dyspnoea is increased by the inha- 
lation, but anaesthesia is speedily established, and then the breathing be- 
comes much calmer than before. Dr. Toss, who has also emploj^ed it, 
reports equally favorably of its effects ; and Mr. Marsh, who has seen it 
administered in at least twenty cases, believes that, when carefully and 
slowly given, it is most beneficial. It must be remembered, however, that, 
owing to the asphyxia, the sensibihly of the child is usually much blunted, 
so that, even without anaesthesia, the operation has appeared to us to cause 
but little pain, and has been borne by the little patients with scarcely any 
struggling. 

After-Treatment. — Immediately after the successful performance of 
the operation, and the satisfactory adjustment of the canula, an almost 
incredible change occurs in all the s} T mptoms of the patient. The wild 
restlessness of the little sufferer, with the agonized, appealing glances at 
those surrounding the bedside, and the frantic clutching at the throat as 
though to tear it open to admit air ; the lividity of the surface, the noisy, 
hissing stridor of the respiration, all vanish as though by magic. Very 
frequently the child falls into a placid sleep, the skin and lips regain their 
normal color, and the breathing becomes regular, full, and nearly as silent 
as in health. This calm is not, however, to be of long duration ; there 
are frightful dangers still to be undergone, from which nothing but the 
most assiduous care and skilful treatment can enable the patient to escape 
with life. 

It may, in fact, be asserted that the much greater proportion of success 
which has of late years attended this operation, is to be attributed chiefly 
to the more judicious after-treatment which patients receive. Indeed, 
Trousseau has most truly said, with regard to the importance of this por- 
tion of the management of the cases: that tracheotomy, badly performed, 
but well treated afterwards, will end favorably in a third of all cases ; 
whereas, tracheotomy excellently executed, but badly treated afterwards, 
will almost invariably be followed by a fatal termination. 

It might, consequently, have been added to the contraindications al- 
reacty enumerated, that, unless we can secure constant and skilful attend- 
ance upon the case after the performance of the operation, there can be 
but little hope of obtaining a favorable result. 

Wherever it is in any way possible, the constant presence, by day and 
night, of a physician or student of medicine should be secured for four 
or five days after the operation. When this is utterly impossible, all of 
those engaged in nursing the case should be carefully instructed how to 
act in the event of any emergency, so that the child shall never be without 
the presence of some one competent and ready to render the prompt as- 
sistance which is frequently necessary to avert instant death. The details 
of the attention necessary will be given a little further on. 

One of the first points to which careful attention must be paid, is to 
give to the air to be inspired through the canula as much as possible the 
temperature and degree of moisture that the air attains by its normal pas- 
sage through the mouth and nose. Various means have been recom- 



120 PSEUDO-MEMBRANOUS LARYNGITIS. 

mended to secure this object; thus, a piece of loose coarse sponge, wetted 
with tepid water, and enveloped in a piece of gauze, may be applied over 
the canula ; or, as directed by Trousseau, " the neck of the child may be 
surrounded by a cravat of knitted wool, or a large piece of muslin or 
gauze, so that the patient expires into this thick tissue, and inspires the 
air impregnated by the warm watery vapor which the expiration has just 
furnished." 

This is the only means adopted by Trousseau ; but we may, in addition, 
by the aid of a spirit-lamp, keep shallow dishes of water evaporating in 
the room, and at the same time employ a thermometer to regulate the 
temperature of the chamber, which should be uniformly kept at from ^0° 
to 12° F., though the air should be changed frequently, so that it may be 
pure and fresh. 

By careful attendance to this clear but long-neglected indication, we 
not only prevent the rapid cliying of the mucus in the canula and tra- 
chea, but, as Trousseau asserts, avoid to a great extent the occurrence of 
pneumonia or bronchitis as sequelae of the operation. 

In regard to the treatment of the wound itself, we have already alluded 
to the advantage of placing a piece of lint spread with cerate, or a caout- 
chouc riDg, beneath the collar of the canula to prevent any irritation of 
the skin. Xo sutures should be introduced into the skin incision, as the 
efforts during coughing will soon tear them out. Trousseau strongly 
advises that the edges of the wound should be cauterized daily for the 
first three or four days, with solid nitrate of silver, in order to prevent 
the formation of diphtheritic deposit. 

It very soon becomes necessary, despite every care to render the in- 
spired air moist, to cleanse the inner tube of the coating of viscid, partly 
dried mucus which collects on its interior, and to effect this, the inner tube 
should be removed as frequently as is necessary. The frequency with 
which this withdrawal is required varies in different cases, but it may be 
stated as a general rule, that it should be performed from four to twelve 
times in twenty-four hours. 

When the tube is clear, the respiration is almost noiseless, and hence 
the supervention of noisy breathing is usually the indication of some ob- 
struction in the inner tube, which should immediately be withdrawn and 
cleaned. 

The drying of the mucus in its interior may be partially prevented by 
dropping, every half hour, a few minims of tepid water into the mouth of 
the canula, and by smearing the inner surface of the tube with pure 
glycerine, every two or three hours. Some years ago, 1 Barthez recom- 
mended instillations of tepid solutions of chlorate of soda through the 
canula after tracheotomy, in the hope of effecting the softening of the 
false membranes, and their more rapid and complete expulsion. Al- 
though he was inclined to attribute a beneficial effect to the practice at 
the time, it appears to have since fallen into disfavor even with its origi- 
nator. 

1 Bull. G6n. de Ther., May 30, 1858. 



AFTER -TREATMENT. 121 

We have ourselves einphyyed lime-water in several cases, and always 
with obvious relief. TVe were induced to use it from its well-known sol- 
vent action upon pseudo-membranous exudation, and have generally em- 
ployed it by atomizing warm lime-water through the canula every few 
hours, or so often as the breathing becomes noisy and labored, despite 
the removal and cleaning of the inner tube, from the collection of viscid 
mucus or pseudo-membrane below the end of the canula. The atomiza- 
tion has been continued for a moment or two, and has usually excited 
cough, while at the same time it softened the viscid mucus and enabled 
the child to reject it through the tube. So great, indeed, is the relief at 
times thus afforded, that in one case the little patient asked frequently 
that the use of the atomizer should be repeated. In all probability it does 
good, partly by its mechanical action in exciting cough, partly by the 
softening effect of the watery spray, but partly also, we are inclined to 
believe, by the action of the lime upon the mucus and pseudo-membranes. 
TVe are also in the habit of directing that the child shall breathe for a 
few minutes in every hour, the steam from slaking lime, though in all 
probabilitj*, this does not contain an appreciable amount of the lime itself. 

It occasionally happens, however, that the breathing becomes noisy and 
obstructed and remains so even after the withdrawal of the inner tube, 
and the use of the atomizer. The cause of the obstruction then probably 
consists in the presence near the end of the canula, either of a collection 
of dried mucus or of a piece of false membrane too large to escape through 
the canula. If, under these circumstances, an access of dyspnoea should 
ensue, the strings securing the canula should be instantly cut and the 
outer tube withdrawn. If this be followed by the rejection of false mem- 
brane and a return of quiet respiration, the canula may be returned ; but 
if there is reason to fear that the trachea contains false membranes too 
large to escape through the tube, it is better to allow it to remain out 
permanently. 

Millard (loc. cit.) recommends that the external tube should always be 
removed at the end of twenty-four hours after the operation, when the 
track of the wound is usually patulous, being lined by plastic lymph, and 
after waiting a few minutes for the rejection of false membranes and 
cauterizing the wound, be again introduced. 

In those cases which progress favorably, it soon becomes necessary to 
decide at what date the canula shall be finally removed. It is evident 
that this should be accomplished so soon as possible, as the tube acts the 
part of a more or less irritating foreign body in the neighborhood of 
delicate and important structures, and yet it is only in rare cases that 
the patient can endure its removal before the sixth or seventh day. 

At the end of the fifth day, therefore, the experiment may be tried of 
plugging the mouth of the canula with a little roll of wool, to learn in what 
degree the larynx has become patulous. Should the child be unable to 
take a single respiration, the experiment may be deferred for several 
days, but should breathing be performed through the mouth for several 
minutes, the measure may be repeated daily, in order to gradually accus- 
tom the larynx to a resumption of its function. 



122 PSEUDO-MEMBRANOUS LARYNGITIS. 

About the seventh or eighth cla3 T the tube may be removed for an hour 
or two ; and, if its abstraction be well borne, be finally withdrawn the 
following day, and the wound closed by bringing its edges together with 
adhesive plaster. It is very necessary to observe the caution that the 
canula must never be removed unless some one competent to replace it 
is at hand. It occasionally happens, however, that the larynx remains 
impervious for a much longer time, and cases are recorded in which it 
has been impossible to remove the canula for fifteen, twenty-five, forty- 
four (Trousseau), or even one hundred and twenty-six (Fock) days ; or 
even for months or } T ears. The causes which thus delay the period at 
which the tube can be removed, are summed up by Mr. Marsh (loc. cit.), 
as follows : 

1. Obstruction of the larynx by false membranes, which have been 
known to linger in its cavity for at least fourteen days after the operation. 

2. A chronic inflammation and thickening of the mucous membrane of 
the larynx, which ma}^ remain after the acute disease has passed off. 

3. A narrowing or complete obliteration of the passage of the larynx, 
b}" the growth of granulations above and around the canula. 

4. An impairment or complete loss of those functions of the muscles 
of the laiynx which regulate the admission of air through the rima giot- 
tidis. 

5. Adhesions of the opposed surfaces of the vocal cords. 

After the removal of the tube, the wound heals, either by contracting 
from the circumference toward the centre, when air escapes until the very 
last day ; or the tracheal wound first closes, and the cicatrization then 
advances externally. The average time occupied by this process of cica- 
trization, is about one month, though it may be completed in two weeks 
or be protracted for two months. 

Among the results which have been known to follow the prolonged 
stay of the canula in the trachea, are necrosis of the tracheal cartilages, 
and ulceration about the wound, or of the trachea around the canula, 
which, in several cases, has been followed by fatal hemorrhage. Suppu- 
ration among the deeper structures of the neck, even extending into the 
anterior mediastinum, has been noticed in a few instances, when the 
deep-seated tissues of the neck had been much disturbed. 

General Treatment. — Having carefully discussed the management 
of the canula and the treatment of the tracheal wound, it remains to say 
a few words in regard to the general treatment of the patient after the 
operation. 

The most essential point to be secured is, unquestionably, the proper 
alimentation of the child. It is, however, frequently very difficult to in- 
duce it to partake even of the most tempting food. We should endeavor 
to persuade it to take, as before the operation, nourishing animal broths, 
beef-tea, milk, custard, chocolate, wine-whe} r , or weak milk-punch. If, how- 
ever, these are refused, and the child expresses a desire for any other di- 
gestible article of food — as the breast-meat of fowl, finely minced, or the 
soft portions of oysters, or eggs — the taste should be gratified. Occa- 
sionally ice cream will be taken willingly, when other food is refused; or, 



GENERAL TREATMENT. 123 

when both wine-whej' and milk-punch are rejected, iced wine and water, 
or brandy and water will be relished. Unfortunate^, however, it not 
rarely happens that, owing partly to the soreness of the throat and partly, 
undoubtedly, to the pain caused b} T the canula during the movements of 
the trachea in deglutition, the little patient utterly refuses to swallow 
more than a mere sip of iced water. Under such circumstances, so serious 
a complication is abstinence, that Trousseau recommends that it should 
be forced to take a little food. "Do not fear," he sa} T s, "to employ in- 
timidation. In such cases I have often — assuming an apparent severity, 
the expression of which I have exaggerated — forced the child to eat, and 
so have prepared the way for a recoveiy, which, without this, seemed to 
me impossible." 

Even by this means, however, it may be impossible to secure the ad- 
ministration of a sufficient amount of nourishment, and we would then 
advise the use of nutritious enemata, consisting either of the yolk of one 
egg^ beaten up in an ounce of milk, or of one ounce of beef-tea, and given 
about every four hours. If they appear to irritate the rectum, and are 
not retained, one or two drops of laudanum may be added to each enema. 

In comparatively rare cases there exists, in addition to this unwilling- 
ness to eat, a positive difficulty in swallowing liquids. This results from 
the inaction of the vocal cords and epiglottis, which allow the fluid to 
pass through the glottis into the trachea and bronchia, causing violent 
cough and escaping through the artificial opening. The child is so 
alarmed by this, that it sometimes refuses all nourishment, and can only 
be supported by nutritious enemata. Under these circumstances, Trous- 
seau advises that all liquid aliment should be interdicted, and that the 
food of the child should consist of very thick soups, vermicelli boiled in 
milk or broth, hard eggs, eggs very much cooked in milk, and rare-cooked 
meat, in rather large morsels. If the thirst becomes ardent, he allows 
pure cold water, taking care to give it either some length of time after, 
or immediately before, the meals, in order to avoid vomiting. This diffi- 
culty in swallowing rarely begins until three or four days after the oper- 
ation, and does not usually last beyond the tenth or twelfth day. Some- 
times, as M. Archambault has suggested, the child is enabled to swallow 
with ease, by closing the canula with the finger at the moment of deglu- 
tition, but at other times this fails entirely. 

In many cases the difficulty in inducing the child to swallow, after the 
operation, is so great that all medication must be suspended, excepting 
the administration of small doses of opium, by the mouth or by enema, 
which we would advise to be continued. 

Whenever it is practicable to give remedies, however — without inter- 
fering with the ability and willingness to take food — it is very important 
to bear in mind that despite the very great relief which the operation 
may have afforded, it has by no means put a stop to the disease, but has 
simply afforded the system another chance to overcome and cast off the 
constitutional affection. 

Of course, the use of emetics must be suspended, and so if, on any 
theoretical ground, any depressing remedies have been employed, they 



124 PSEUDO-MEMBRANOUS LARYNGITIS. 

should be discontinued. But we should recommend, under such circum- 
stances, that the use of the combination of chlorate of potash, tincture of 
chloride of iron, and sulphate of quinia should be persisted in. 

We subjoin the histories of two cases of true croup, which have lately 
occurred in our practice, and which will serve to illustrate clinically the 
remarks that we have made upon this disease. 

In both cases tracheotonry was performed by Dr. H. Lenox Hodge, in 
one instance with complete success, but in the other with a fatal result. 

The first and successful case was under the care of Dr. R. Boiling, of 
Chestnut Hill, and was seen in consultation by Dr. J. F. Meigs, and, sub- 
sequently to the performance of the operation by Dr. Hodge, by Drs. 
Edward Khoads and William Pepper. 

The second case was visited by both of us from the first ; and was at- 
tended, after the performance of the operation by Dr. Hodge, with the most 
zealous and skilful care, by Drs. Wharton Sinkler and M. Longstreth. 

Angina with Membranous Exudation on Tonsils — Membranous Laryn- 
gitis : Tracheotomy at end of second day — Complete Recovery. 

Case 1. F. W., set. Y-J years, a delicate child, who at the age of 4 years 
had suffered from a severe attack of true croup, from which he recovered 
without the operation. On December 23d, 1868, he was noticed to have 
the symptoms of an ordinary cold in the head, with slight sore-throat, some 
d} T sphagia, and laryngeal cough ; he was visited and prescribed for by Dr. 
R. Boiling. On December 24th, the cough persisted, and there was slight 
coiwza and redness of fauces, but without any membranous deposit or 
any croup} T symptoms. 

He was ordered small doses of Kermes mineral, Dover's powder, and 
nitrate of potash, and counter-irritation to the throat. 

At 5 a.m., December 25th, the child, who had gone to sleep quietly, 
waked in a frightful paroxj^sm of ctyspncea, gasping, clutching at its 
throat, and with oppressed whispering voice. 

Emetics of alum were given and produced free emesis, but without the 
rejection of any false membrane, nor was any yet visible in the fauces. 
The powders were continued. 

The dyspnoea persisted aud grew steadily worse ; the voice remained 
suppressed. Membranous exudation was noticed in the evening on the 
tonsils, and during the following night, the obstruction to respiration 
became so intense that, after consultation with Dr. Meigs, tracheotomy 
was performed by Dr. H. Lenox Hodge. The trachea was opened just 
below the isthmus of the thyroid gland. No false membrane could be 
seen at the level of the opening, nor was any rejected. 

A few hoars later it became necessary to remove the canula, cut an 
oval piece from the trachea, and replace the tube, during which proceed- 
ing artificial respiration had to be maintained. 

The neck was surrounded by gauze. Nutritious enemata, with small 
doses of laudanum, were given eveiy two or three hours. Cream and 
brandy were given by mouth, and the attempt was made to give quinia 



ILLUSTRATIVE CASES. 125 

and iron, but the child absolutely refused to take it. The breathing be- 
came somewhat easier, but at 9 a.m., December 26th, it was 66, and the 
pulse 160. 

The internal tube was frequently removed and cleansed of very thick 
viscid mucus, which rapidly collected in it ; and the other treatment was 
continued. In the afternoon it became evident that the internal tube 
was entirely too small, and it was therefore abandoned and the external 
one alone retained. Warm lime-water was now atomized down the tube 
every two hours, and on the first occasion of its use was followed by 
the rejection of a large piece of thick, dark-gray, glue-like false mem- 
brane. This was followed b}~ marked relief to the dyspnoea. 

The child was kept gently under the influence of opium ; and was nour- 
ished by enemata of beef-tea, f 3j ; brandy, f 3j ; tr. opii, gtt. iv, given 
every three hours ; which were retained unless they provoked a fecal dis- 
charge, which happened two or three times. The urine was passed freely, 
and was not albuminous. 

The respirations were conducted solely through the tube, and once 
during sleep fell as low as 32. 

December 2T. — Still refused to eat, and the bowel also became some- 
what irritable, so that several of the enemata were rejected. The respi- 
rations varied from 35 to 48 ; the pulse from 132 to 140. The treatment 
was continued; the atomization of lime-water through the tube being 
repeated every three hours. Towards the close of each interval the face 
became flushed, and the child grew restless, throwing the arms about 
excitedly, at times leaping up in bed, and turning round so as to lean 
forward on the pillows and bury his face in his hands, or else looking 
round with an appealing expression. The atomization was always followed 
b} 7 cough, and the rejection of pieces of false membrane and thick puri 
form matter. Towards evening he began to swallow some food. 

December 28. — The tissues of the neck had become so much infiltrated 
and swollen, that the canula was no longer long enough to reach from the 
cutaneous surface into the trachea ; it was in this way pushed forward 
till it obstructed the tracheal opening and caused great dyspnoea. It was 
consequently removed, and the child, though much exhausted, sank into a 
gentle refreshing sleep, with quiet regular breathing. The tube was not 
replaced, the breathing being readily performed through the wound. 
There was still marked indisposition to take food, and for a few times he 
was forced to swallow by holding his nose and pouring beef-tea down his 
throat ; this was not, however, continued, as the effort exhausted him 
very much, owing to his most violent resistance. The discharge from 
the trachea through the wound was quite fluid, purulent, and very fetid. 
A solution of carbolic acid, gtt. x, in Oss of tepid water, was atomized 
through the wound ; and the atmosphere of the room was kept impreg- 
nated by atomizing a stronger solution about the chamber. 

During the. day he swallowed more food; gr. \ of opium was given 
twice ; his circulation and respiration improved. 

December 29. — Condition still improving. Respirations 28, quite full 



126 PSEUDO -MEMBRANOUS LARYNGITIS. 

and deep, -without rales ; pulse had fallen steadily from 114 to 84, and was 
more full and strong. The color of surface was better. Respiration car- 
ried on partly through the month. 

December 30. — The child passed a very comfortable day. The respi- 
rations were about 24; the pulse 18 to 86, soft, full, and strong; the 
capillary circulation good. Food was taken much better, the child eat- 
ing a croquette made soft with cream, the soft part of several oysters, a 
small piece of breast of partridge cut fine and rubbed up with butter and 
salt, and drinking sheriy wine and water, and rich chocolate. The dis- 
charge had lost to a great extent its offensive character. Took gr. ss of 
opium at night, and slept five hours quietly. 

December 31. — The child's condition was better in every way. The 
wound was contracting, the edges of the tracheal opening white and 
clean, and granulations beginning to project over it. The cough was 
stronger and more laryngeal, and the voice stronger and clearer, though 
still whispering. A good deal of the discharge was now raised into the 
mouth and expectorated. The gauze with which the wound had been 
covered was changed for a piece of patent lint, to encourage the hnynx 
to gradually resume its functions. 

From this time the case steadily improved. The matter expectorated 
grew more and more mucoid, thin, whitish, and scanty, and finally ex- 
pectoration ceased almost entirety. The general symptoms rapidly im- 
proved, though he remained weak and nervous for six weeks. The ex- 
ternal wound was covered with patent lint, at first of one, then of several 
thicknesses, and he gradually regained the power of breathing through 
the larynx, and of speaking. The larynx seemed quite clear after Jan- 
uary 2d, 1869, eight days after the operation. The wound granulated 
from the bottom outwards, and was entirety cicatrized by the end of six 
weeks ; by which time he was about the house, and had returned to his 
studies to occupy his mind, as he was very fretful and nervous. 

November 1, 1869. — F. W.. remains perfectly well, and is indeed enjoy- 
ing more robust health than for several years before this attack of mem- 
branous croup. 

Angina with membranous patches on tonsils; Membranous Laryngitis; 
Tracheotomy on tenth day ; Death on thirteenth day {fifty-eight hours 
after operation). Autopsy. — False membrane extending from tracheal 
wound to third division of bronchi ; right lung emphysematous; left 
lung collapsed ; blood dark and fluid. 

Case 2. K. B., girl, set. 6 years and 1 month ; rather tall for her age. 
Her parents are healthy ; but she herself had suffered much from spas- 
modic asthma during infancy and first dentition. Since then she has 
enjoyed good health. On the morning of Tuesday, October 5th, 1869, she 
appeared unwell with a little croupy cough, which passed off in the middle 
of the day, and she was allowed to play in the square for a couple of 
hours. On Friday, 8th, her cough was worse, but still she seemed so 
bright that she was allowed to play about the room ; but in the afternoon 



ILLUSTKATIVE CASES. 127 

she complained of sore throat, and Dr. J. F. Meigs was called and found 
small patches of exudation on the tonsils. 

]&. Potass. Chlorat., . . . . .• . gr. ij. 

Tr. Ferri Chloridi, gtt. v. 

Every third hour in a teaspoonful of syrup and water. 

During the night, violent dyspnoea, with noisy gasping breathing came 
on, for which emetics were employed with some relief. 

On Saturday, 9f/?, there were patches of membranous exudation on the 
fauces and tonsils. The cervical lymphatics were only slightly enlarged. 
The breathing was difficult and stridulous ; the voice feeble, small, usu- 
ally whispering, but when raised by an effort, was rather piping and 
shrill; the cough was short and smothered. There was no coryza. Treat- 
ment continued, and inhalations of the vapor from slaking lime ordered 
every hour. 

On Sunday. 10th. — The child was restless, with at times marked Jacti- 
tation ; face flushed and expression anxious ; respiration labored ; inspira- 
tion imperfect, with shrill stridor ; expiration prolonged and stridulous. 
Xo expectoration. Membrane still visible in fauces. No albumen present 
in urine. Pulse frequent, skin hot and moist. Treatment continued, and 
cloths wrung out from hot water applied to the throat. 

Monday, 11/7?. — Condition about the same; the degree of d} r spncea vary- 
ing from time to time with degree of spasm, but the breathing still con- 
tinuously labored and stridulous. Treatment continued, and frictions 
with turpentine liniment directed to be made to the throat. Marked un- 
willingness to eat. 

Tuesday, 12th. — There was marked improvement in the child's con- 
dition. The breathing was easier and less stridulous ; the cough less 
frequent and looser, with a few thick yellowish purulent sputa ; the voice 
was raised with less difficult}* - and was clearer and stronger. There was, 
however, the same faucial pain and obstinate indisposition to eat. The 
fauces were still red and swollen, and a small thin patch of exudation 
was visible on one of the tonsils. The treatment was continued, and 
the child also took a little port wine and water and beef tea, and had 
nutritious enemata of egg given every four hours. 

Wednesday, 13th. — The condition of the fauces was better, the breathing 
easier and the voice more clear. The skin was still heated, pulse fre- 
quent, and there was still indisposition to eat. 

During the ensuing night, the breathing again became more oppressed 
and tighter, with some return of stridor. The voice also became sup- 
pressed and whispering. The circulation was somewhat obstructed, the 
face becoming flushed and the lips rather dark. 

Thursday, lith. — These symptoms were aggravated, and in the even- 
ing there was marked jactitation and restlessness. The respirations wore 
40 in the minute, and stridulous, with prolonged expiration ; and, during 
the inspiratory effort, with violent action of the external respiratory mus- 
cles, elevation of the shoulders, and recession of the base of the chest and 
of the epigastrium. There was also complaint of pain at the epigastrium. 
The cough was infrequent, short, smothered, and muftied. The eyes were 



128 PSEUDO-MEMBRANOUS LARYNGITIS. 

anxious, staring, and prominent, with large pupils. The pulse was fre- 
quent, 140, and small. 

During the night there was a steady aggravation of all these symptoms. 
The respirations rose to 46, and became extremely obstructed, the reces- 
sion of the base of the chest and at the epigastrium being unusually 
marked during inspiration. The voice was whispering and almost sup- 
pressed ; the expression strained, appealing, and anxious ; the face deeply 
flushed and the lips livid. There was the same complaint of constant pain 
at the epigastrium. 

Friday 15th, at 1\ A. if., respirations 36, pulse, 136. Tracheotomy 
was performed by Dr. H. Lenox Hodge, the trachea being opened just 
below the isthmus of the thyroid gland, and a small oval piece excised 
from its walls. A good deal of venous hemorrhage occurred during the 
operation, but stopped immediately after the trachea was opened, and the 
tube adjusted. 

No anaesthetic was used, but the child made no resistance, and evi- 
dently was slightly benumbed from asphyxia. Soon after the operation 
the respirations grew more eas} T , a large piece of false membrane was 
thrown off through the opening, the flush disappeared from the face, and 
the features became composed and placid. 

Very soon after the operation the respirations fell to 28, and through- 
out the d&y remained easy and regular. The pulse fell to about 120. The 
child slept well, but would eat but little, and still had enemata of beef- 
tea, f^i, q. t. h., given it. The air of the room was kept pure, but warm 
and moist. The canula was covered with folds of gauze moistened with 
lime-water, and the wound was covered with a piece of greased linen, so 
as to protect it from the canula. The inner tube was removed every hour, 
cleaned, anointed with glycerine, and returned. Warm lime-water was 
atomized through the tube every three hours, and always produced strong 
coughing, with the expectoration of thick purulent matter, and occasion- 
ally of flakes of tough white false membrane. All medication was sus- 
pended, save the administration of gtt. ii, or iii, of Tr. Opii Deodorata 
sufficiently often to keep the child gently under its influence. During the 
ensuing night the internal tube was removed, owing to the difficulty in 
expelliug the thick viscid mucus. 

Saturday, lQth. — The respirations were 24; pulse 116. During the day 
the child took more beef-tea and wine and water, but still had nutritious 
enemata given. There was great thirst, and she still complained of pain 
in swallowing. There was no coryza, and very slight, if any, enlarge- 
ment of the cervical lymphatics. 

Towards evening, breathing again grew obstructed, evidently from ac- 
cumulation of mucus and pseudo-membrane below the end of the tube, 
which was consequently removed. Its removal was followed by the dis- 
charge of several large pieces of false membrane through the wound, the 
edges of which were well consolidated by lymph. The breathing quickly 
became noiseless, easy, and tranquil again. During the following night 
the child enjoyed some refreshing sleep, and took more nourishment. The 
atomization of lime-water through the tracheal opening was repeated 



ILLUSTRATIVE CASE — AUTOPSY. 129 

about every two hours, and with such great relief that she several times 
asked for it herself by sigos, as it each time provoked cough, and caused 
the expulsion of thick purulent matter, dried mucus, and shreds and flakes 
of false membrane. Urine was discharged freery, and contained no al- 
bumen. 

• Sunday, IT//?. — In the morning she appeared quite comfortable. The 
voice was still whispering, but the cough seemed looser, and she expelled 
purulent matter more freely through the opening; no false membrane was 
discharged. ■ The thirst was still great, but the child took beef-tea more 
freely. The bowels have for several days been opened two or three times 
daily. Respirations 20-25 ; quite full, without recession of the base of 
the chest. Pulse 130-136, of rather better volume. Hands fairly warm, 
though at times there was a little tendency to coolness. The wound was 
evidently contracting. Slight emplrysema of the base of the neck, which 
caused complaints of pain about the neck and shoulders. 

At 4 p.m. it was observed that the breathing was again growing ob- 
structed, and that there was recession of the base of the thorax during 
inspiration. Lime-water was freeby atomized through the opening, but 
without causing any discharge of membrane. The difficulty of respiration 
increased until 5 1 P. M., when suddenly s3<mptoms of asphyxia appeared. 
Prolonged efforts at artificial respiration were made, and life was thus 
maintained for a short time, but no essential relief was afforded, and 
death soon followed, on the thirteenth da}^ of the disease and fift3'-eight 
hours after the operation. 

The chest was frequently ausculted throughout the course of the case. 
Before the operation it was impossible to isolate any respiratory murmur, 
owing to the loud, snoring, whistling, and cooing tracheal and bronchial 
rales. After the operation, and still more after the final removal of the 
canula, a faint respiratory murmur could be detected, mingled with, the 
above rales. On the morning before death only was there an obscure 
flapping sound transmitted to the ear with the tracheal and bronchial 
rales, but even then it was indeterminate in character. 

During the efforts at artificial respiration, a long tubular false mem- 
brane was ejected. It had evidently been the immediate cause of death. 

Autopsy, twenty-four hours after death. Brain not examined. 

Thorax and air-passages. — The wound in the neck looked well, without 
pseudo-membranous exudation. The larynx itself could not be examined. 
A long false membrane, extending from the tracheal opening down through 
the right bronchus to the third or fourth division, lay loose in the trachea, 
having been detached from the mucous membrane. In the bronchia it was 
still slightly attached, but separated readily on traction. It was firm, very 
tough, and white, and, in the upper part of the trachea, at least one line 
thick. Below the bifurcation it was tubular for the rest of its course ; and 
in its terminal portions grew softer and more yellowish. There was also, 
in the trachea, a large patch (1J inches long by \ inch wide) of false mem- 
brane, of dull white color, and tightly adherent. Upon raising it, nu- 
merous little delicate fibrous prolongations were seen attaching it to the 
mucous membrane. Beneath this patch the mucous membrane was deeply 



130 DISEASES OF THE LUNGS AND PLEURA. 

reddened, dry, excoriated-looking, and slightly roughened by minute ele- 
vations. There was no enlargement of the mucous follicles. The vas- 
cularity of the mucous membrane diminished in the lower part of the 
trachea, and was but slightly marked in the secondary divisions of the 
bronchi. Xo ulceration was seen at any point. There was no pseudo- 
membrane in the left bronchus or any of its branches, and the mucous 
membrane here was less reddened than on the right side. In all proba- 
bility the false membrane removed immediately after death had come from 
the left bronchus. The right lung was largely distended, the posterior 
border dark and congested, but the rest of the organ pale and emphy- 
sematous. The left lung was dark, purplish, non-crepitant, collapsed, 
and yielded on section an abundant flow of dark, airless, bloody serum. 
No pleurisy or pleural effusion. 

Heart. — The left ventricle was very firmly contracted and empty, and 
the tissue of its walls hard, tough, and florid red. The walls of the right 
ventricle were relaxed, and the cavity filled with fluid dark blood, without 
any clots. Xo excess of pericardial effusion. 

The liver and kidneys were gorged with dark blood. 



CHAPTER II. 

DISEASES OF THE LUNGS AND PLEURA. 

GENERAL REMARKS. 

It would be difficult, perhaps, to over-estimate the importance to the 
medical practitioner of a thorough knowledge of the different diseases of 
the lungs and pleura, as they occur in children. The diseases of the re- 
spiratoiy organs — and much the most frequent of them are pneumonia and 
bronchitis — cause, according to Dr. West, of London, very nearby a third 
of all the deaths under five years of age in England ; while not above one 
child in four dies under that age from diseases of the nervous system, and 
not above one in seven from those of the digestive system. In this coun- 
tiy , it would seem, from the bills of mortality, that a larger proportion of 
children die of diseases of" the digestive than of the respiratory system. 
But, while this is true, there can be no doubt that the diseases of the lat- 
ter system are deserving of our utmost attention, since not only are they 
of constant occurrence and of fatal tendencj', as idiopathic affections, but 
since, also, the}' frequently appear as complications in the course of other 
diseases, adding greatly thereby to their severity and danger. In measles, 
for instance, by far the most frequent cause of danger is the occurrence 
of some inflammation of the luugs or pleura. In scarlatina and typhoid 
fever, bronchitis and pneumonia are very common accidents, and recent 
researches have shown that in hooping-cough and in all states of great 
debility and prostration, a certain change in the condition of the pul- 



ATELECTASIS PULMONUM. 131 

monary tissue, to which the term collapse has been applied, is very apt 
to occur. 

The morbid condition of the lung last referred to, that of collapse, is 
one that has been well understood only within a few years past, and yet 
it is so important a one. in a practical point of view, as to excite a feel- 
ing of surprise that it had not been discovered before. 



AETICLE I. 

ATELECTASIS PLLMONUM, OR IMPERFECT EXPANSION OF THE LUNG-. 

The title of atelectasis pulmonum, from arsXrjs, imperfect, and ezravcs, 
expansion, was first employed b} T Dr. Edward Jorg, to designate a con- 
dition of the lungs observed b} T him in new-born children, a condition in 
which larger or smaller portions of those organs had never been pene- 
trated b}' air. The respiration of the infant had been established, in such 
cases, more or less imperfectly, at birth, and some parts of the pulmonary 
tissue had, consequentby, never undergone expansion under the distend- 
ing influence of the inspiratory act ; these undilated parts continued in 
the foetal state. 

In addition to this congenital form of imperfect expansion of the lung- 
tissue, this condition is met with at all ages of life, though with especial 
frequency in young children, as the consequence of a collapse of portions 
of the once expanded lung, or, in other words, of their return to the foetal 
or unexpanded state. To this latter form of imperfect expansion, the 
terms post-natal atelectasis, collapse, and foetal condition have been given. 
Before the discoveiy of its real nature was made, it had often been de- 
scribed also under the well-known names of carnineation and lobular 
pneumonia. We shall designate it by the title of collapse or post-natal 
atelectasis, while under that of congenital atelectasis pulmonum, we shall 
describe the congenital variety of imperfect expansion. 

CONGENITAL ATELECTASIS. 

Anatomical Appearances. — In congenital atelectasis the parts of the 
lung most frequently affected are the posterior portion and lower edge of 
the inferior lobes, the middle lobe of the right lung, and the languette 
and lower edge of the upper lobes. In some instances, that we have 
examined, the greater part of the lower lobes of both lungs, while, in 
others, still larger portions of these organs have been found to present 
this condition. The imperfectly expanded portions of the lung are of a 
dark-red, or purplish color, and are diminished in size, so as to be de- 
pressed below the level of the healthy parts. They are solid to the touch, 
and yet they have not lost their cohesive properties, as the^y are neither 
friable, easily torn, nor readily penetrable by the finger; their cut surface 
is perfectly smooth ; they do not crepitate under the finger, and no air- 
bubbles are seen in the fluid squeezed out by pressure; they sink when 



132 CONGENITAL ATELECTASIS. 

thrown into water. They, in fact, resemble exactly the foetal lung. The 
most convincing proof of the real nature of this condition is obtained by 
the inflation of the lung. TVhen this is done, the depressed, hard, and 
dark-colored portions — unless the subject from whom the specimen has 
been taken ma}' have lived long enough to have allowed the different 
tissues of the lung to become adherent — rise to their natural level, be- 
come elastic, soft, and crepitating, and change, under the influence of 
the entering air, from a dark and livid tint, to the rosy or pink color of 
health}' pulmonary tissue. In recent cases, this inflation is performed 
with great ease and with perfect success, while in other instances, in 
which the child has lived for some weeks or months, the distension is 
either effected only by strong efforts, or in a very imperfect manner, or 
it may fail entirely, owing to some permanent change having taken place 
in the tissues of the unexpanded portions. In a case that occurred to 
ourselves, the subject of which died at the age of fourteen months, of 
acute pleurisy of the right side, after having presented, at birth and 
throughout its short life, many of the symptoms of atelectasis, the infe- 
rior two-thirds of the lower lobe of the left lung exhibited in the greatest 
perfection all the atelectasial characteristics. The whole of the unex- 
panded part was distended by means of inflation with a blowpipe, but 
only after repeated and powerful expiratory efforts ; and Dr. E. Wallace, 
who made the examination, assured us that he was obliged to use a degree 
of force much greater than he ever employed to inflate health}' adult lung. 
In most cases, the foramen ovale and the ductus arteriosus are found 
to be still open, or the latter has but partially closed. 

The causes of congenital atelectasis have not been satisfactorily ascer- 
tained. The only conditions that have been well made out as probable 
causes, are : original debility of the infant, from any cause that has inter- 
fered with its proper development in utero, as feeble health on the part 
of the mother during pregnancy, or multiple pregnane}'; and acquired 
debility, brought about by the fact of the infant's being exposed at birth 
to unfavorable hygienic influences, and particularly to those which inter- 
fere with the proper performance of the respiratory act, as cold, a vitiated 
and close atmosphere, and the use of too heavy or tight clothing. A very 
hurried and rapid labor has been thought to cause, in some instances, 
this imperfect expansion of the lung-substance. In a case that occurred 
to one of us (see Am. Journ. Med. fife, Jan., 1852, p. 83), the only expla- 
nation of the condition, which seemed at all plausible, was that the pla- 
centa had been separated from the uterus at too early a period of the 
labor, in consequence of the violent and rapid character of the latter, so 
that the child was for a short time before birth cut off entirely from its 
connection with the mother,— a time sufficient so to lower its vital forces, 
as to bring on a condition resembling syncope, and to deprive it of the 
muscular strength necessary on entering the world, to produce a full ex- 
pansion of the thoracic cavity, and so of course to effect a dilatation of 
all parts of the lungs. 

Symptoms.— The symptoms depending on congenital atelectasis vary a 
good deal in different cases. There are some, however, which exist in 



SYMPTOMS. 133 

most of the cases. These are the following : the child comes into the 
world feeble and weak, and instead of crying vigorously and loudly the 
moment or very soon after it is born,- it fails to cry at all, or the cry is 
low and weak, or it is whimpering or wailing; the color, instead of being 
brick-red or dark-red, is pale and whitish, leaden, or livid ; the muscular 
movements, which, in healthy children, are strong and vigorous, are in 
these, languid and slow, or there are none or scarcely any, the limbs being 
relaxed and motionless. If the breathing is observed, it is found to be 
short, high, and imperfect, and it is evident that the thorax is but imper- 
fectly dilated at each movement of respiration. When these symptoms 
exist in a very marked degree, the infant either dies soon in a state of 
asphyxia, or, the muscular force slowly increasing, the respiration grad- 
ually improves, and the child is, after a longer or shorter time, either out 
of danger, or it falls into the same state as that of one in whom the symp- 
toms have been from the first less severe. Under the latter circumstances, 
the infant continues feeble and weak. It breathes shortly, rapidly, and 
imperfectly, but often without an} T appearance of labor. The cry is rare, 
and, when heard, is low and feeble, or there is a constant plaintive moan, 
which is very characteristic, and strongly expressive of exhaustion, with 
each respiration. The color continues pale and whitish, or it is bluish, 
and the temperature of the extremities is lower than natural. The child 
sleeps the greater part of the time, and is unable to nurse or nurses very 
feeblv, but can swallow when fluid is poured into the mouth. In such 
cases as these, the infant does not necessarily die, but will often recover 
when properly treated. In favorable cases, the symptoms just enumer- 
ated may last from a few hours to a day or two, or even a few weeks, 
without much change ; then, under the influence of correct hygienic and 
medical treatment, thej will often begin to improve. The color becomes 
less pale or less bluish ; the muscular movements are somewhat stronger ; 
the child begins to cry, and in a louder tone ; the act of swallowing is 
easier and more perfect, or the infant is able to suck when applied to the 
breast, at first feebly and only for a moment, and then more strongly ; 
the respiration becomes slower, fuller, and more natural, and gradually 
the dangerous symptoms disappear. 

In unfavorable cases, on the contrary, the respiration fails to improve, 
but becomes more and more short, quick, and imperfect ; the temperature 
of the body falls ; the color of the surface changes, becoming leaden, 
bluish, or even livid, the change showing itself first in the neighborhood 
of the mouth, and in the hands and feet, and extending gradually to the 
rest of the body ; the difficulty in swallowing becomes greater, and very 
generally some spasmodic twitchings begin to show themselves about the 
muscles of the face. The respiration is very often attended with slight 
wheezing or rattling, and the convulsive movements returning frequently, 
and becoming more violent and more general, the child dies in convul- 
sions, or it sinks very slowly and gradually, without convulsions, as though 
in a state of s}*ncope. 

There is another s3 T mptom of imperfect expansion of the lungs in new- 
born and very young infants, which ought not to be passed unnoticed. 



134 COLLAPSE OF THE LUNG IN EARLY WEEKS OF LIFE. 

It is one mentioned by Dr. George A. Kees, of London, in an essay on 
this subject (London, 1850), and which is regarded bj^him as the pathog- 
nomonic symptom of the condition. It is an altered movement of the 
ribs in respiration. During the inspiratory effort the ribs are seen to 
move inwards toward the mesial line of the trunk, instead of outwards 
as in ordinary respiration, thus diminishing instead of expanding the 
transverse diameter of the thorax. The explanation of the altered move- 
ment is as follows : when the diaphragm descends, the lung ought to ex- 
pand in such a waj T as to fill up the increased space produced in the tho- 
racic cavity by the descent of that great muscle. Instead of this being 
the case, however, the lung is collapsed and inexpansive, and cannot en- 
large sufficiently to fill up the space alluded to, so that there would remain 
a vacuum in the chest were it not that the thoracic walls are driven in- 
wards b}~ the pressure of the atmosphere upon their outer surface. In a 
case that we saw ourselves in a child fourteen months old, who had pre- 
sented symptoms of atelectasis from birth, and in whom we found after 
death very extensive collapse, this symptom was very marked. The base 
of the thorax was indented on both sides by a deep gutter or depression, 
which remained depressed and unchanged during the inspiratory move- 
ments, or which, indeed, rather became more distinctly visible during 
those motions, so that the chest presented the curious spectacle of dila- 
tation or expansion in its upper parts, during inhalation, and of contrac- 
tion or collapse at its base. 

Symptoms of Collapse in the early Weeks of Life. — Before 
taking up the regular consideration of post-natal collapse, as it occurs at 
all ages of childhood, we wish to refer, for a moment, to that condition as 
it appears in the first few weeks of life, in infants who have exhibited no 
sign of it whatever, perhaps, at the moment of birth. We desire to do 
this now, because the symptoms which it gives rise to resemble much 
more those of congenital atelectasis, than those of collapse in children 
over a few months old. And let it be remarked, that these symptoms 
are very different, and much more severe and threatening than those of 
collapse at later periods. They are in fact those of cyanosis, and, in some 
instances, are as strongly marked as those observed in the worst cases of 
that condition, caused by malformation of the heart or great vessels. The 
cyanosis and other symptoms of disordered circulation, evidently depend 
on the obstacle offered by the collapsed and condensed portions of lung- 
tissue to the discharge of blood from the right side of the heart. Though 
this obstacle to the venous circulation is doubtless the chief cause of the 
symptoms in these cases, we cannot but think ourselves, that the great dif- 
ference between the symptoms of congenital atelectasis, as well as of post- 
natal atelectasis occurring in the first few weeks of life, and the collapse 
of later periods, must be explained in part, at least, by the fact that the 
foetal openings, the foramen ovale, and ductus arteriosus, and especially 
the former, are still patulous, or in such a condition that they may be re- 
opened underpressure, and so allow a portion of the contents of the over- 
loaded and congested right side of the heart, to pass into the left auricle, 
thence into the left ventricle and aorta, and so to the whole body. 



SYMPTOMS. 135 

Iii this form of atelectasis, the child ma}^ have been born perfectly 
healthy, or only weaker than usual, or it may have had some difficulty in 
establishing the respiration, which, however, has afterwards been effected 
in the most complete manner. Some days, or even weeks after birth, 
from a cause disturbing the function of respiration, portions of the lung 
may collapse, and give rise to the different symptoms of that condition 
in the manner above described. The most important of these symptoms 
are difficulty of breathing, consisting either in an increased or diminished 
rate of that function, diminution of the muscular power, cyanotic hue of 
the skin, and slight or severe spasmodic phenomena. In a case that oc- 
curred to one of ourselves (see Am. Journ. Med. Sc, loc. cit.), a child 
who had exhibited at birth, and for five clays after, every appearance of 
fine health, was observed on the sixth clay to cry rather violently in the 
morning. At one o'clock in the day he began to moan, and appeared 
distressed ; at two he ceased to moan, became bluish, and seemed to lose 
his breath. He was placed in a bath, in which the blueness passed off, 
but the breathing continued irregular and uneven. He soon became blue 
again, and breathed slowly and irregularly, but had no spasm. At about 
four o'clock, another paroxysm occurred, in which the whole surface be- 
came first bluish, and then black, while, at the same time, the trunk and 
limbs became stiff and rigid under the influence of tonic muscular spasm, 
and the respiration was slow and imperfect. After the attack had lasted 
for some moments, the blueness and spasmodic phenomena disappeared, 
but the child remained in a state of stupefaction. There were two slight 
parox3'sms of convulsive stiffening between this and evening, and later 
in the evening there was still some blueness, with irregular and short 
respiration. During the night the breathing was short and uneven, and 
attended with moaning, but on the following clay the symptoms had dis- 
appeared entirely, and there was no return. 

In another case the symptoms of collapse did not appear until the 
twenty-fifth day after birth. The infant had been hearty and strong at 
birth, and had established its respiration fully and completely. Between 
the birth, however, and the time of the attack, circumstances connected 
with the lactation had caused the development of diarrhoea with thrush, 
which had debilitated the child a good deal. On the day of the attack, 
frequent sneezing, with stuffing of the head, and some cough, seemed to 
show the existence of cold, and, on the same day, the child was unfortu- 
nately exposed, owing to the accidental opening of one of the gas-burners, 
to the inhalation of some gas. Late in the evening, a slight whistling or 
striclulous sound was heard in the breathing, the skin became suddenly a 
little bluish, and a slight convulsion followed. During the night there 
were frequent and strong convulsive seizures, always preceded and fol- 
lowed by deep blueness of the mouth, hands, and feet, and it was noticed 
that the least disturbance, as lifting or nursing, or changing the position, 
alwa} T s brought them on. The next morning the attacks continued, but 
with diminished violence, under the effects of treatment, and they ceased 
after the middle of the day. The color of the skin had now changed : it 
had become rosy red, instead of pale or blue, and the hands and tool. 



136 ATELECTASIS PTJLMONUM. 

which had been cold, were now warm and natural. There was no return 
after this. 

In a third case a female infant, who had been perfectly well at birth 
and up to the moment of this attack, was put suddenly into a bath by the 
nurse on the eighth day, directly after its waking from sleep. The child, 
who was not thoroughly waked up, seemed greatly terrified, and began 
to scream most violently. Instead of removing the infant from the water, 
the nurse persisted in holding it immersed for some minutes, when it be- 
came deeply blue, and partially convulsed ; it frothed at the mouth and 
nose, seemed to be suffocating for breath, and appeared to be dying. 
These symptoms continued for three-quarters of an hour, when they grad- 
ually passed away, and it fell into a heavy sleep. When we saw the in- 
fant, soon after this, the only signs of disorder that remained, consisted 
of an unusual paleness, drowsiness, and an expression of feebleness. 
Some three hours later, it waked, nursed, and from that time seemed 
quite well. 

In a fourth case, a child born apparently well, with the exception of its 
having had a rather frequent respiration, and who nursed very well on 
the second and third day, was attacked on the fourth day with blueness, 
moaning, short and panting respiration, and then with slight convulsive 
symptoms. It was unable to nurse, and though kept perfectly still, and 
fed from time to time with small quantities of milk and brandy, became 
gradually more deeply blue, had parox3-sms of very slow respiration and 
circulation, with general convulsive seizures, and died at the end of 
twenty-four hours. 

The reader will also find this form of cyanosis referred to in our article 
on that disease. 

Diagnosis. — There can be no difficulty in detecting the nature of the 
case when the imperfect expansion exists from birth, and when the phy- 
sician is present at that event. 

When, however, collapse of the lung-tissue continues after birth, and 
the pbysician is called upon to determine at the age of some days, weeks, 
or even months, the cause of the feeble health and puny growth of the 
child, or to explain those sudden attacks of collapse in very young in- 
fants who had previously well established to all appearances the respira- 
tion, the diagnosis becomes more difficult. In the former class of cases, 
attention to the following points will usually, however, enable us to make 
a correct diagnosis. The previous history is particularly important, since, 
' in all such cases, it will be found that the infant was either still-born and 
resuscitated with more or less difficulty, or that it was born weak and 
feeble, and that the respiration had not been established as thoroughly 
and completely as it ought to have been. Dr. Kees states that certainly 
half of the cases of this form, in his own practice, occurred in twins, and 
that they were all born in a more or less completely asphyxiated condi- 
tion. The present symptoms are also very important. The feeble ap- 
pearance of the child, and its puny growth, in connection with its past 
history, and the absence, as ascertained by careful examination of the 
case, of other morbid conditions to explain the general ill-health, ought 



PROGNOSIS — TREATMENT. 137 

to direct the attention of the physician to the true nature of the disease ; 
and if we add to these considerations the local thoracic symptoms, the 
short, rapid, and imperfect breathing, with, perhaps, the altered move- 
ment of the ribs, the indentation instead of expansion during inspira- 
tion, mentioned above ; the absence of fever ; and the existence of the 
physical signs of more or less extensive solidification of the pulmonary 
tissue, without those of pneumonia; there will seldom be any difficulty in 
forming a correct diagnosis. 

The cases described under the head of collapse in the early weeks of 
life ma}' be readily understood from the simple fact that the symptoms 
cannot be satisfactorily explained, by referring them to any other condi- 
tion than that of collapse of portions of the lung, with impeded and de- 
ranged circulation. 

Prognosis. — The condition of imperfect expansion of the lungs in a 
new-born child, does not necessarily cause it to die immediately or very 
soon after birth. The fate of the child will depend very much upon its 
degree of innate strength and vigor, and upon the kind of hygienic con- 
ditions to which it may be consigned. When the child is well developed, 
and not enfeebled by any fault in the mother's health during the preg- 
nancy, but merely by some momentaiy condition that has occurred during 
the labor, there is every reason to hope that proper hygienic and medical 
treatment maj T restore it to health. The clanger is greatest in those who 
continue weak and feeble in spite of the proper measures of care and 
treatment for some days or weeks after birth. We have a record of ten 
examples of this condition in new-born children, in nine of which the 
symptoms persisted during a period varying between six hours and five 
days. Of these, seven lived, while three died in from twenty-one hours 
to three da} T s. 

The prognosis of the second class of cases — those in which collapse 
occurs suddenly in a few days or weeks after birth, and after the appar- 
ently complete establishment of respiration — will vary, of course, with 
the violence of the symptoms. Of five cases of this kind that came under 
our observation, recovery took place in three in spite of the most danger- 
ous and alarming symptoms, while in two death occurred in a period of 
about twenty-four hours. 

Treatment. — The treatment of congenital atelectasis resolves itself 
almost entirely into the employment of such means as tend to invigorate 
the general health of the child, and to promote the activity of the respira- 
tory act. In a recent case, one dating from birth, in which the function 
has always been imperfect, and in which there are present great feeble- 
ness, drowsiness, and paleness or blueness, the room in which the infant 
is placed should be kept up to a temperature of 10° or 75°, and the child 
should be abundantly covered with warm clothing. Perfect quiet, or at 
least very gentle motion, is very important, and when there is an}' dispo- 
sition to deep blueness or to convulsive movements, attention to tins 
point is essential. It is in such cases, and in those in which these symp- 
toms come on a few days or weeks after birth, that the position recom- 
mended by the late Dr. C. D. Meigs, for the treatment oi' cyanosis neon- 



138 ATELECTASIS PULMOXUM. 

atorum, was found by hiin so useful. This position is one upon the right 
side, with the head and shoulders raised at an angle of 45 c . It is ob- 
tained hy arranging pillows in such a way as to form a plane inclined at 
that angle. Upon this the infant is placed, and orders are given that it 
is not to be moved at all, if possible, or only with the greatest care and 
gentleness, for twenty-four or forty-eight hours. There can be no doubt 
that this position and the attendant repose have, in man}' cases recorded 
by Dr. C. D. Meigs, and in several that we have seen ourselves, been of 
very great use in controlling the symptoms. Its good effects in c} T anosis 
were supposed by him to depend on the fact that the septum auricularum 
becomes, in this position of the body, horizontal, so that the blood in the 
right auricle must rise against gravity in order to pass through the fora- 
men ovale, while, at the same time, the valve of that opening is disposed 
to fall down by its own weight, and close the foramen, and is, moreover, 
pressed downwards hy any blood that may enter the left auricle from the 
pulmonary veins. This explanation will apply, of course, only to those 
cases of atelectasis accompanied b} T very extensive and deep blueness or 
purple color of the surface, in which we may suppose that so much of the 
pulmonary tissue is solidified, as to produce a degree of obstruction to 
the passage of blood from the right side of the heart into the lungs, suffi- 
cient to overload the right ventricle and auricle, until the latter pours a 
portion of its contents into the left auricle, thus causing admixture of the 
two kinds of blood. In a large majority of the cases of atelectasis, how- 
ever, this explanation of the benefit resulting from the treatment referred 
to, cannot be received, as there is no reason to suppose that in them the 
slight cyanotic sj'mptoms present indicate anything more than the exist- 
ence of a moderate degree of congestion of the right side of the heart, 
unattended by any escape of blood from the right into the left auricle. 
In such cases the position on the right side is useful, because it is the one 
most favorable to a full and easy performance of the respiratory and cir- 
culatory functions. It leaves the left side free and unembarrassed, so that 
the heart can act with the greatest possible freedom, while the partial 
elevation of the head and shoulders renders the movements of the chest 
more easy and complete than when the bod} T is lying on a horizontal sur- 
face. The perfect quiescence which constitutes a part of the treatment is 
also very important, as in many recent and particularly in cyanotic cases, 
the symptoms are greatly aggravated, and convulsive attacks often brought 
on by moving the child, especially if this be done suddenly or rudely. 

Perhaps the most important point of all in the treatment of this affec- 
tion, especially when the symptoms tend to become persistent, is the mode 
of nutrition of the child. If possible, the infant should always have a 
good breast of milk, and if unable to suck, the milk ought to be drawn 
by means of a breast-pump, and given to the child in small quantities 
from a spoon. About two or three teaspoonfuls may be given at first 
every half hour or hour, and the quantity gradually increased until the 
child gains strength enough to be put to breast. If breast-milk cannot 
be procured, cow's milk and water may be substituted, in the proportion 
of one part of the former to two or three of the latter. The only medi- 



COLLAPSE OF THE LUNG. 139 

cines to be given are, at first, while the child is still very young and weak, 
mild stimulants, of which the best, in our opinion, is fine old brandy. Of 
this about five drops may be given each time that the milk is taken ; or, 
we may make use of from three to five drop doses of the aromatic spirit 
of hartshorn, or of proper quantities of wine-whey. 

When the symptoms of congenital atelectasis tend to persist for seve- 
ral weeks or months, and when we first see the patient some time after 
birth, the chief points to be attended to in the treatment are, as before, 
the mode of nutrition, which ought to be by nursing and the use of gentle 
stimulants and tonics. Brandy, wine, or Huxham's tincture of bark, are 
the best stimulants, whilst quinine, in the dose of a quarter or half a grain, 
three times a day, extract of cinchona, in the close of from one to three 
or four grains, three times a clay, or iron in the form of Quevenne's 
powder, or in that of the iodide, are the best tonics. 

COLLAPSE OF THE LUNG, OR POST-NATAL ATELECTASIS. 

General Remarks. — By collapse of the lung is meant the return of 
that organ to its fcetal or unexpandecl state. It is in fact a condition of 
atelectasis or imperfect expansion of its vesicular structure. The terms 
collapse or post-natal atelectasis are employed to contradistinguish it 
from congenital atelectasis, the former being applied to imperfect expan- 
sion as it occurs in lung-tissue after previous expansion, and the latter, 
as stated in the preceding article, to the same condition as it exists in 
children who have never expanded certain portions of the pulmonary 
substance. 

The true nature of collapse of the lung was never understood, and its 
great practical importance never appreciated, until since the year 1844, 
when MM. Legendre and Bailly published, in the Archives Generates de 
Iledecine their researches on the subject. Since then various observers 
have repeated the investigations of those gentlemen, and thrown new 
light upon the matter. Among the most important of the later writers 
on this subject, we may mention Dr. Charles West, of London, MM. 
Hardy and Behier, of Paris, Dr. W. T. Gairdner, of Edinburgh, and 
MM. Killiet and Barthez, in the second edition of their work. 

This discovery in pathology was one of very great value, not merely 
because it renders our knowledge of the morbid conditions of the lungs 
more exact and philosophical than it ever was previously, but because it 
explains certain anatomical changes in the pulmonary structures, often 
before noticed and described, but never satisfactorily accounted for; and 
still more, because it points to methods of treatment much more rational 
and much more successful than those einphyyed under the influence of 
former ideas as to the nature of the lesions alluded to. The most impor- 
tant result of the new views, is the disclosure of the fact that several 
lesions met with after death, which were formerly thought to depend on 
inflammation of the affected tissue, are in reality the consequences of col- 
lapse or obliteration of the vesicular structure of the lung, and not of in- 
flammation, as was at one time supposed. The lesions alluded to are 



140 COLLAPSE OF THE LUNG. 

those which have been hitherto described under the names of lobular 
pneumonia and carnifieation. 

The peculiar character of the lesions met with in many of the supposed 
cases of pneumonia., had often drawn attention and been commented upon, 
before their real nature came to be understood. The points of difference 
between these alterations and those of true pneumonia were particularly 
noticed b} T MM. Denis, De La Berge, Rufz, Rilliet and Barthez, Dr. 
Gerhard, and Dr. West. In fact, M. Rufz, and MM. Rilliet and Barthez, 
both approached very near the truth in regard to these lesions, each 
comparing them, but the former at an earlier period than the latter, to 
the condition of the lung of a foetus that has never breathed. The latter 
writers, in the article on pneumonia, in their first edition, have described 
a condition of the lung which differed so much from ordinary pheumonia, 
as to create a great difficulty in their minds as to its true nature, and to 
it thej' applied the term carnifieation. They were on the very verge of 
detecting its real character ; they did in fact suggest its real character, 
but were so possessed with the idea that it must be the result of some in- 
flammatory action, as to neglect to pursue their own suggestion, but 
endeavored to explain the condition on the ground that it was " one 
mode of termination of pneumonia, or else chronic pneumonia." The 
following passage, quoted from their work (lere ed., t. i, p. 74), will show 
how closely the} T approached the truth : " The first idea that enters the 
mind on examining this tissue (calcification), is, that it resembles the 
lung of a foetus that has not breathed ; we should feel inclined to say that 
the pulmonary vesicles had not yet been dilated under the influence of 
the thoracic expansion, and had not, therefore, admitted air into their 
interior ; or, rather, it would seem as though they had been obliterated 
by some attack of disease, perhaps inflammation, without, however, re- 
maining engorged, and after having lost the power of dilatation." 

In the second edition of their great work, MM. Rilliet and Barthez 
adopt, in great measure, the views of MM. Legendre and Bailly, and of 
Dr. Gairdner, not only in regard to carnifieation, but also in regard to 
the yet more important lesion hitherto generally called lobular pneu- 
monia. 

But it is not only the condition of the lung, called carnifieation, that 
has been shown to consist, not in inflammation, but in a collapse of the 
pulmonary tissue. A much more important consequence of the recent 
researches has been the discovery, that in a very large majority of cases 
the so-called lobular pneumonia, generalized lobular pneumonia, and 
pseudo-lobar pneumonia of different writers, are also the results of col- 
lapse of the lung, variousby combined with bronchitic inflammation and 
congestion of the pulmonary tissue. The latter discovery has lessened 
very much the importance of pneumonia as a disease of early life, while 
it has augmented in the same proportion that of bronchitis, for it has 
shown that a very large number of cases, formerly regarded as true in- 
flammation of the parenchyma of the lung, are in fact cases of bronchitis 
combined with collapse of the tissue of the organ. 

Now that the nature of collapse of the lung, in connection with bron- 



ANATOMICAL LESIONS. 141 

chitis. and sometimes, also, with true pneumonic inflammation or con- 
gestion, has been made known, a number of symptoms occurring in the 
pulmonary affections of children, which were formerly obscure and ir- 
regular, have become easily explicable. It had been often observed that 
many of the supposed pneumonias of children did not present the same 
symptoms, pursue the same course, nor require the same treatment as 
the pneumonia of adults, or as some cases of the disease in children. In 
a great many of the supposed cases there was an unusually large amount 
of bronchial inflammation, the general s} T mptoms were much less acute 
than was to be expected in a parenchymatous inflammation, and what 
was most singular of all. the physical signs of solidification of the lungs 
were very variable and uncertain, there being present on one clay the 
signs of simple bronchitis, while on the same clay or the following, and 
over the same region of the thorax, these would be associated with or 
masked by the signs of induration of the lung; and again, in a daj or 
two, the symptoms indicative of condensation might disappear, to be 
succeeded yet again by those of simple bronchial inflammation. The 
effects of treatment seemed also to point clearly to a radical difference 
between the lobular or broncho-pneumonia of children, and the acute 
phlegmasial disease of adults. It was .found, in fact, that depletory 
measures were seldom borne well in the lobular pneumonia of children, 
while in the pneumonia of the adult, and in some acute cases occurring 
in early life, which presented the same general symptoms and the same 
plrvsical signs as pneumonia in the adult, antiphlogistics, as is well 
known, are amongst the most successful remedies that can be made 
use of. 

Anatomical Lesions. — Collapse of the lung (post-natal) occurs in two 
different forms, the diffused, and the limited or lobular. The only differ- 
ence between the two forms is in the number of lobules affected, and their 
mode of distribution. In the diffused variety, a large number of adjoin- 
ing lobules collapse, and give a condensed and solid appearance to larger 
or smaller portions of the lung, most frequently to the edges, merely, of 
one of the lobes, but at others to the greater part or the whole of a lobe, 
or even the major part of a lung. In the lobular variety, on the contrary, 
single lobules or clusters of lobules become collapsed in different parts 
of a lobe or lung, and the affected portions take the form of irregular, 
hardened patches or tumors, situated upon the surface, or disseminated 
through the interior of the pulmonary texture. In the former kind of 
collapse, the appearance of the altered portion of the lung is somewhat 
that of lobar pneumonia, and it is to these cases that the terms general- 
ized-lobular, pseudo-lobar, carnification, and splenization, have been 
applied; while in the latter kind, the isolated, and distinct condensed 
portions, have been described by the term lobular pneumonia. 

The peculiar or fundamental characters of collapsed pulmonary tissue, 
are the same in both varieties. We will mention them as succinctly 
possible, and then compare them with those of pneumonia, for the reason 
that it is with the lesions of that disease that those of collapse have been 
hitherto confounded. 



142 COLLAPSE OF THE LUNG. 

Collapsed lung is generally of a dark violet color, but it may be much 
darker in tint, and even black, when it is much engorged with blood. Its 
consistence is alwa} T s changed ; the condensation may amount merely to 
slight hardening, with a diminution of the crepitation, or it ma} T be very 
dense with an entire absence of crepitation, in which case portions thrown 
into water sink rapidly. Though more or less hardened, the tissue still 
retains a certain degree of flaccidhYv and suppleness. When cut into, the 
surface is seen to be smooth and uniform, having somewhat the appear- 
ance of muscle, and presenting no granulations. Pressure or scraping- 
cause the exudation of more or less semi-transparent bloody serosity. 
Close examination shows that the organic elements of the tissue, the ves- 
sels, bronchia, cellular tissue, &c, can still be distinctly traced. Lastly, 
inflation of the lung distends the condensed parts, and gives to them 
again, more or less completely, their natural physiological characters. 

MM. Rilliet and Barthez, in their second edition, treat, at considerable 
length, of congestion of the lung as a very constant accompaniment, and 
as a very important element in the state of collapse. They regard this 
congestion as being connected nearly alwaj T s with bronchitic inflamma- 
tion, and as being not merely a passive state, but as exhibiting phenom- 
ena, in most instances, which prove it to be in some degree an active 
condition. They sa}' (loc. cit., t. i, p. 428): "We readily acknowledge 
that a state of debility, prolonged dorsal decubitus, and the obstruction 
to the circulation thus occasioned, facilitate the production of this con- 
dition, and give to it the appearance of a simple passive congestion. But 
we believe that there exists, moreoA^er (frequently, if not always), a realty 
active and even inflammatory movement." They regard this opinion as 
proved chiefly by the fact that they have found the texture of the affected 
parts to be somewhat softened, as shown by the facility with which they 
are torn by the finger or by scraping with a scalpel ; by the swelled and 
turgid condition the tissues exhibit ; by the quantity of sanguineous or 
sero-sanguineous liquid which escapes on pressure ; and by the presence 
of a serous exudation around the pulmonary vesicles, while the interior 
of the vesicles appears to be healthy. The last-mentioned condition they 
found upon their own observation, and upon a microscopic examination 
made b} r M. Lebert. 

The color is different in the two alterations, being, in collapse, purple 
or livid, and, in pneumonia, brownish-red or fallow-red. In pneumonia 
the pleura covering the hepatized portions is often covered with false 
membrane, showing thereby the inflammatory nature of the disease ; in 
collapse this is rarely the case, and only when there is some accidental 
concomitant pneumonia. The density of the lung in the two conditions 
is of a different kind : in pneumonia it is hard to the touch, and unyield- 
ing ; in' collapse it always retains a certain degree of flaccidity and soft- 
ness, like that of muscular tissue. In pneumonia the diseased part is 
turgid and swelled, so that it projects above the common level of the sur- 
rounding surface; in collapse, on the contrarj^ it is shrunken and de- 
pressed below the neighboring parts. In pneumonia the effects of the 
inflammatory process on the tissues is very strongly marked, and pro- 



ANATOMICAL LESIONS. 143 

duces changes in them very different from those occasioned hy mere 
collapse. In the former disease the cohesive properties of the pulmonary 
structure are very much lessened, so that the inflamed parts are readily 
penetrated by the finger, and are easily torn; in simple collapse, on the 
contrary, the diseased part is as firm and resisting, or even more so, than 
in health; whilst in collapse occurring in bronchitis and attended with 
congestion, though the cohesion of the tissues is somewhat lessened, it is 
never nearly so much so as in pneumonia. In the true hepatization of 
pneumonia, a cut surface always presents a granular aspect, while in 
collapse, on the contrary, it is smooth and even. On scraping a cut sur- 
face it is found that, in the former alteration, a plastic, fibrinous matter, 
of a yellowish, orange, or gray color, comes off on the knife; while, in 
collapse, only some semi-transparent bloody serosity is scraped off. In 
the former, the anatomical arrangement of the lobules cannot be seen, as 
the inflammation attacks indifferently the lobules themselves, the inter- 
lobular septa, aud parts of neighboring lobules ; but, in the latter, the 
alteration can always be seen to be more or less regularly confined to the 
lobules, the cellular interstices between the lobules remaining more or less 
apparent ; so that in pneumonia the alteration is not bounded at all by the 
outlines of the lobules, while in collapse the alteration always affects, more 
or less, the lobular form. To conclude, the effects of inflation are alto- 
gether different in the two conditions. M. Legendre (Becherches Anatom.- 
Path. et Clin, sur quelques Mai de VEnfance, p. 164) states that air can 
never be made to penetrate b} r inflation into a completely hepatized lung. 
Neither in hepatization of the lobar form, nor in true partial hepatization, 
has he ever been able, even with the utmost effort, to push air into the 
inflamed tissues. After repeated trials, the tissue remained compact and 
friable, and sank as rapidly as before when thrown into water. In the 
fcetal state, on the contrary, the slightest effort sufficed to fill and distend 
the collapsed air-cells, and to give to the altered portion its natural ap- 
pearance, excepting that it became more red in consequence of the oxy- 
genation of blood contained in the capillaries. Dr. Gairdner (Pathol. 
Anat. of Bronchitis, etc., Edinburgh, 1850, pp. 13, 14) remarks that, 
though this test "is very useful in demonstrating the nature of the le- 
sion, in a favorable case, to one not familiar with its character, I do not 
believe it to be applicable to the determination of the presence or absence 
of pneumonia in those mixed cases in which alone there is airy difficulty. 1 ' 
He has observed, in fact, that partially pneumonic lung ma}^ be inflated 
when the affection is recent and combined, as it frequently is, with bron- 
chitic collapse, while in the latter lesion, in its purest forms, complete 
inflation is often very difficult or impossible after the collapsed state has 
been of some duration. 

The part of the lung in which collapse is most frequently mot with, 
depends somewhat on the form of the alteration. In the diffused variety, 
it ma}^ affect a more or less considerable portion of either or both lungs. 
but is most common at their posterior part. The lobular variety is most 
common on the anterior edges, but may, like the diffused, occur in any 
other part. As a general rule, the alteration is most frequent at the 



144 COLLAPSE OF THE LUNG. 

periphery of the organ, where its edges are thin, as along the margins of 
the lobes, in the languette of the upper lobes, and at the bases of both 
lungs. The parts just named are those most distant from the primary 
air-passages ; they are those in which the inspired air would arrive last, 
and with the least force of impulsion. 

Causes. — It has been generally acknowledged that there are two prin- 
cipal causes by which to explain the production of collapse of the lung. 
These are the presence in the bronchia of some condition which acts as 
an impediment to the ready passage of the inspired air, and a want of 
power in the muscular apparatus by which the function of respiration is 
carried on. To these Dr. Gairdner adds another, — the inabilh\y to cough 
and expectorate, and thus remove the obstructing mucus, — but this is, in 
fact, included in the preceding. , 

The most important of the above-mentioned causes is evidently the 
deficient respiratory power, since this is noticed and insisted upon by all 
observers. It has been found, in fact, that collapse seldom occurs to any 
considerable extent except in children who are exhausted and debilitated. 
The debility may be congenital, it may be the result of wearing diseases, 
as diarrhoea, hooping-cough, measles, typhoid fever, &c, or it may de- 
pend on exposure to unwholesome and enfeebling hygienic conditions. 
It is easy to understand that a child who is either born weak and feeble, 
or who becomes so in after years from any of the causes just alluded to, 
must lose, with the general decay of the strength of the bodj r , some por- 
tion of the muscular power by which alone a complete and efficient dila- 
tation of the thoracic cavity can be accomplished, and that, when this is 
the case, the inspirations must be short and imperfect, and that portions 
of the lung most distant from the primary air-passages, not being reached 
by the inspired air, will remain in an unexpanded or collapsed state. If 
we add to this state of feeble respiratory power, the presence of opposing 
secretions in the air-tubes, whether these be the consequence of bronchial 
inflammation, as they are in the immense majority of cases, or, as Dr. 
Gairdner suggests they may sometimes be, the mere natural secretion of 
these tubes, accumulated for the want of power to throw them off, it be- 
comes abundantly easy to comprehend the mode of production of collapse, 
in at least some of the examples. 

Whether a simple deficiency of inspiratory force alone, without ob- 
structing mucus in the bronchia, will give rise to collapse, is a somewhat 
mooted point. Dr. West agrees with MM. Legendre and Bailly, in the 
opinion that it is often due to the inspiratory power having been inade- 
quate to overcome that natural elasticity of the lung which opposes a full 
dilatation of the organ. Dr. Gairdner (loc. crt.,p. 33) cannot "see reason 
to believe with Dr. West, that mere debility, apart from any obstruction 
in the tubes, is a sufficient cause for collapse in the child." He remarks, 
and with strong show of reason, that the very fact of the lesion being 
usually more or less lobular, or partial in its distribution, appears to in- 
dicate special circumstances of a local kind, as having a marked influence 
on the production of this affeetion. What is of most consequence, how- 
ever, to the working physician, as an important practical truth, is the 



CAUSES. 145 

fact stated by several observers, and adverted to by Dr. Gairdner him- 
self, that in some cases no signs whatever of obstructive bronchitis or of 
bronchial accumulation can be discovered during life. Before leaving 
this point, we desire to call attention to the opinion of Hasse (Pathol. 
Anat.. Syd. Soc. ed., p. 253), that, though this partial introduction of 
air might be deemed at variance with the laws of respiration, inasmuch 
as the atmospheric pressure must necessarily distend the entire lung 
equally, not to the exclusion of a lobe, and still less, to that of a lobule, 
the objection falls to the ground when it is considered that the operation 
of these laws is the result of previous muscular action. He refers to the 
fact that in pleurisy one-half of the thorax, and in partial pleurisy certain 
portions of that cavity, do not share at all in the movements of the re- 
mainder. "We need, therefore, 1 ' he says, "be at no loss to understand 
how defective breathing may originate in a merely partial activity of the 
intercostal or other respiratory muscles. 7 ' 

Dr. Gairdner, as already stated, considers as one of the causes of col- 
lapse, an inability to cough and expectorate, and thus to remove the ob- 
structing mucus. The views which he expresses on this point are very 
interesting, and also, we think, very important. He states that Laennec 
supposed the expiratoiy force of respiration to be weaker than the inspira- 
tory, while in fact the experiments of Hutchinson and Mendelsohn, to 
which he refers, prove that though ordinary inspiration is more of a mus- 
cular act than ordinary expiration, yet the residual effective force for over- 
coming adventitious obstruction is very considerably greater in expiration. 
" The forced or muscular expiratory act is, in fact, about one-third more 
powerful, as measured b} T its effect upon a pressure-gauge, than the ex- 
treme force of inspiration ; and it is this force which is thrown into action 
when obstruction in the tubes is to be overcome." In the act of cough- 
ing, the air in the vesicles is brought to bear upon the obstructing sub- 
stance within the bronchia, at a maximum amount of outward pressure, 
and with the additional mechanical advantage of a sudden impulse, so 
that the practical efficiency of the expiration in forcing air through ob- 
structions must be far greater than that of inspiration. It is clear, there- 
fore, that if the secretions in the air-passages be so abundant or so viscid 
as to interfere materially with the entrance and exit of air, they must 
necessarily occasion collapse, either partial or total, of the parts be3 T ond 
them, since not only does the air enter with difficulty, but being expelled 
with greater force and in larger quantitj^ than it can be drawn in, the 
amount remaining in the vesicular structure must gradually diminish. 
This effect of obstruction will be still more remarkable when the muscu- 
lar force of respiration is diminished by debility of the patient, for then 
the inabihUy of the inspiratory act to replace the air driven out by expira- 
tion, will be yet more marked than when the muscular powers of the body 
retain their full force. 

There is still another mechanical condition which tends to produce col- 
lapse from obstruction, to which Dr. Gairdner refers. This condition is 
to be found in the form of the bronchial tubes. These tubes are a series 
of gradually diminishing C3dinders, and if a plug of any kind, but espe- 

10 



146 COLLAPSE OF THE LUNG. 

cially one closely adapted to the shape of the C3 T linclers, and possessing 
considerable tenacit} T , be lodged in any portion of such a cylinder, it will 
move with much more difficulty towards the smaller end, and in doing so 
will close up the tapering tube much more tightly against the passage of 
air, than when moved in the opposite direction into a wider space. From 
this arrangement of the parts, it will happen that at every expiration a 
portion of air will be expelled, which, in inspiration, is not restored, owing 
in part to the comparative weakness of the inspiratory force, and in part 
to the valvular action of the plug. " If congk supervene, the plug may 
be entirety dislodged from its position, or expectorated, the air, of course, 
returning freely into the obstructed part ; but if the expiratory force is 
only sufficient slightty to displace the plug, so as to allow of the outward 
passage of air, the inspiration will again bring it back to its former posi- 
tion, and the repetition of this process must, after a time, end in perfect 
collapse of the portion of lung usually fed with air by the obstructed 
bronchus." 

TTe have been thus particular in our consideration of the causes of col- 
lapse, because we are convinced, from personal observation, that it is a 
subject of verj r great importance in practice. Man 3^ times, in the last few 
years, we have met with cases of bronchitis, either primary or secondary, 
in weak and debilitated children, in which the general and local symp- 
toms have pointed clearly to the existence of collapse of the lung, and in 
which, moreover, the good effects of a sustaining and even stimulating 
treatment have shown the great utility of an acquaintance with the nature 
of this affection, and its proper remedies. 

Symptoms. — As collapse of the lung occurs almost alwa3 T s in connection 
with bronchitis, though sometimes, also, after, or concomitantly with 
pneumonia, it is clear that the sj^mptoms which reveal its existence must 
be mingled, in a greater or less degree, with those of the two diseases just 
named. It is true, nevertheless, that it sometimes occurs unassociated 
with more than very slight evidences of any other disease of the lung. 
Cases of the latter kind have been usually observed onty in children 
dying in states of utter exhaustion, in whom the muscular power of res- 
piration has been so greatly weakened, as to prevent a dilatation of the 
thoracic cavity sufficient to cany air into the deeper parts of the lung. 
In such instances, the symptoms of collapse do not show themselves until 
a very short time before death, and they consist in the sudden appearance 
of very rapid and oppressed breathing, with little or no cough, in more or 
less extensive dulness on percussion over different parts of the chest, but 
most commonly the inferior dorsal regions, and in feeble or suppressed 
respiratory murmur, or more commonly a distant and imperfect bronchial 
respiration. In some cases, however, in which there is very little bron- 
chial complication, as shown by the rarity and small amount of the 
catarrhal rales, the symptoms of collapse continue with more or less irreg- 
ularity, as to situation and extent, for periods of several weeks, or even 
months. But here, also, as in the cases previously referred to, the gen- 
eral debilit3 r and low health of the child are strongly marked, and are, 
with slight variations, persistent. As an instance of this kind of collapse, 



SYMPTOMS. 147 

we may cite the following case, which occurred in the practice of one of 
ourselves: 

A boy. between three and four months old, who, at birth, and up to the 
time of this attack, had presented every appearance of strong and vigor- 
ous health, was seized, on the 3d of October, 18-19, with sjonptoms of a 
somewhat irregular and anomalous character, but which we soon suspected 
to be the signs of an intermittent fever. We were induced in part to 
make this diagnosis, from the fact of having attended the mother during 
her gestation of this child, in a severe attack of intermittent fever. At 
the beginning of the sickness, there was some little coiyza, but no cough 
whatever. On the 3d of October, after the coryza had lasted for a few days, 
he became worse, and we were sent for. During the six days following 
this, he had one or two attacks each day of coldness of the extremities, 
followed by violent fever, and ending sometimes with perspiration. He 
was exceedingly fretful, screamed a great deal, was at times drowsy and 
dull, and vomited occasionally. The stools were regular and perfectly 
natural. The breathing was rapid and short nearly all the time, but there 
was no cough whatever. On the seventh daj', the respiration was 100 by 
the watch, and irregular. The child was pale, weak, drowsy, and entirety 
without cough. Percussion revealed nothing, and no rales could be heard. 
On the eighth da}', the breathing was 96, and a slight, dry cough was 
heard two or three times. When roused up, the intelligence of the child 
seemed perfect. On the ninth day, the breathing was 63, and the pulse 
120. There was rather more cough, though still very little, and there was 
a slight return of the coiwza, of which there had been none for several 
days before. Xeither auscultation nor percussion revealed any decided 
change in the lungs. On the eleventh day, the paroxysms of chilliness, 
followed b} T fever, were still noticeable, though there was no clearly 
marked periodicity in the returns. When without fever the breathing 
was 54 ; during the fever it was 6Y. Auscultation revealed nothing de- 
cided. Percussion showed dulness beneath the right clavicle. By the 
seventeenth day, the intermittent nature of the disorder was more de- 
cidedly marked, and under a few doses of quinine the sjunptoms had im- 
proved, so that the breathing fell to 30 during sleep. The cough was a 
little more frequent, though still verjr slight, and it was loose. The coiyza,. 
also, was more considerable, the nasal discharge being quite abundant. 

After this the case went on badly, owing, we think, in great measure, 
to the circumstance of the quinine being abandoned in consequence of 
the opposition made by the parents to its administration, — an opposition 
which we allowed to influence us more than was proper. During Noveni- 
ber and December, the child remained weak, pale, languid, and with un- 
certain appetite, sometimes refusing the breast for a whole clay at a time. 
The quinine was suspended at first on account of the great improvement 
which had taken place in the sjmaptoms, and though resumed afterwards, 
was given in such small quantities, and for so short a time, for the reasons 
just mentioned, as to be of no service. In December the child was very 
ill. It looked badly, having a pale, waxy face, and a dull, languid ex- 
pression, though without any want of intelligence ; it emaciated moder- 



148 COLLAPSE 0? THE LUNG. 

ately, and had occasional vomiting; the stools were natural. At this time 
also it took the mother's breast with some difficulty, and refused artificial 
food altogether. Occasionally during this month there was observed a 
slight blueness around the mouth, and also about the hands and feet. 
Late in the month it was attacked with thrush in a slight degree, which 
lasted several days. In the first week of January, finding that it was fast 
sinking from refusing the mother's breast and artificial food, a wet-nurse 
was procured, and for a few days it seemed to improve a little, but this 
did not last. It grew weaker and thinner, the thrush returned, it had now 
a good deal of loose cough, the abdomen became somewhat contracted 
and felt hard and doughy, and the breathing was very rapid, though not 
greatly oppressed. The child died at last on the 26th of January, having, 
for ten days before that event, looked wretchedly- languid and haggard, 
and having presented for three clays before, slight diarrhoea, loose, fre- 
quent cough, entire loss of appetite, thrush, drowsiness, and, finally, 
coma. 

At the autopsy there were found some fibrinous exudation, and a few 
adhesions over the lower half of the left lung. The lower two-thirds of 
the left and the lower half of the right lung were dark-colored, more 
dense than usual, not friable, and exhibited no granulations on a cut sur- 
face. These portions were in fact collapsed. The upper lobes were spongy, 
crepitant, and healthy. Not a tubercle was found. The foramen ovale 
presented an oval-shaped opening, of the size of a goose-quill. The ab- 
dominal organs were healthy. 

When, as indeed most usually happens, collapse occurs in the course of 
bronchitis, it is associated of course with the symptoms of that disease. 
The bronchitic symptoms have lasted in their usual form for several days, 
having been marked by sonorous, sibilant, and subcrepitant rales, when 
suddenly, or in the space of a few hours, the breathing becomes much 
worse, the pulse rises in frequency but becomes small and feeble, and cer- 
tain changes take place in the plrvsical signs which are very important. 
The subcrepitant rale continues to be heard, but it is associated now with 
prolonged expiration, and a little later with bronchial respiration, which, 
however, is of a different kind from the bronchial respiration of pneu- 
monia, being distant and smothered, instead of near and metallic, as in 
that disease. The percussion becomes, at the same time, dull and ob- 
scure, but never, scarcely, to the same extent as in pneumonia. The 
general symptoms are those of exhaustion, rather than of high reaction. 
The surface is pale or slightly bluish, the skin is either natural in tem- 
perature, slightly warmer than usual, or coolish, the strength is very 
much reduced, and the child appears more seriously ill, and particularly 
more oppressed than the amount of bronchitis present would seem to 
explain. 

As an example of collapse occurring in the course of bronchitis, we 
will give the following case. A girl between two and three months old, 
healthy when born and up to the time of this sickness, saving that she 
was rather paler and smaller than most robust infants, was seized with 
coryza and slight cough, and after a few days with the symptoms of a 



DIAGNOSIS. 149 

mild bronchitis. For two days there was frequent cough, some little 
fever, quick but not oppressed breathing, occasional sibilant and mucous 
rale, perfect ability to nurse, and very moderate restlessness or fretful- 
ness. On the third day, without any apparent reason, the symptoms be- 
came suddenly very alarming. The breathing became extremely rapid 
and most violently oppressed, so that the movements of the chest at each 
respiration were heaving and laborious, the shoulders being lifted high at 
each inspiration, the outer angles of the mouth drawn downwards, and 
the ake nasi widely dilated. There were at the same time abundant sub- 
crepitant, intermingled with dry rales over the dorsum of the chest. In 
this case, moreover, the s3'mptom mentioned by Dr. Rees was very well 
marked. The base of the chest was driven inwards at each inspiration, 
producing at that point an evident constriction, whilst the upper parts 
were lifted high in the effort to carry on the respiration. The cough was 
frequent and racking, and occurred in paroxj^sms. The child was still 
and quiet, pale, had a haggard and exhausted look, was unable to nurse 
at all, and its surface was cool and white, especially that of the extremi- 
ties. These symptoms continued with very little modification for twenty- 
four hours, when, under the use of brandy, administered every hour in 
milk drawn from the mother, of the spirit of Mindererus and paregoric 
perfect quiet, and the assiduous employment of mild revellents, they 
began to moderate, and at the end of another twenty-four hours the con- 
striction at the base of the thorax during inspiration had disappeared, 
the breathing was easy and gentle, the extremities had become warm, the 
child nursed eagerly and abundantly, and, with the exception of a slight 
catarrh, which lasted a few days longer, it was well. 

Collapse depending on bronchitic inflammation, in debilitated children, 
may sometimes last a considerable length of time. In one case, indeed, 
that we saw a few j^ears since, and of which an account was published 
(see Am. Journ. Med. Sci. for January, 1852, p. 98), the symptoms, owing 
probably to the fact that the bronchitis causing the collapse, was an ac- 
companiment of hooping-cough, continued with slight variations in de- 
gree, for a period of about three months, after which the child entirely 
recovered. 

Diagnosis. — The diagnosis of collapse of the lung must alwa} 7 s be more 
or less uncertain where it is of the lobular form, for the reason that the 
collapsed lobules being disseminated irregularly through the pulmonary 
tissue, afford no physical sign by which we can detect their condition. 
The presence of this form ought, however, to be suspected whenever, in 
a chronic disease, and especially in the course of a catarrhal attack oc- 
curring in a feeble and debilitated child, the breathing becomes exces- 
sively quick and labored, the skin pale and coolish, when the base of the 
thorax presents a depression instead of an expansion during inspiration, 
and, especially, when these symptoms occur without there being a suffi- 
ciently severe and extensive bronchitis to explain their existence. 

In cases of collapse affecting a considerable or the greater part oi' a 
lobe, the diagnosis, though still perhaps rather uncertain, is much more 
clear and positive than in the lobular form. In the latter form Ave are 



150 COLLAPSE OF THE LUNG. 

obliged to depend, indeed, almost exclusively upon the rational symp- 
toms, the physical signs being either very slight or entirely null. In 
collapse of considerable portions of the lung-tissue, we have, on the con- 
trary, some very useful physical signs. These are, the existence of dull- 
ness, greater or less, on percussion ; feeble respiratory murmur; prolonged 
expiratory sound, and sometimes bronchial respiration; which, when they 
occur in connection with, and in the course of bronchitis, are usually 
quite sufficient to render the diagnosis easy. 

The onby diseases with which collapse, presenting the physical signs 
just mentioned, could be confounded, are pneumonia and pleurisy. From 
both of these it is usually distinguishable by the absence in collapse, or 
the slight severity, of the reactional symptoms, by the paleness or blue- 
ness and coolness of the surface, by the absence of acute pain, b} T the 
greater severity in collapse of the bronchitic symptoms, and b} T the fact 
that it rareby occurs except in enfeebled, broken-down subjects, or in 
those laboring under severe bronchitis. The character of the physical 
signs, moreover, is different. Though we have dulness on percussion in 
collapse, it is not so absolute as that either of pleurisy with large effusion, 
or that of confirmed pneumonia. The bronchial respiration, too, is in 
collapse, different from that of pneumonia. It is muffled and distant, 
instead of being clear, metallic, and close under the ear, as in pneumonia : 
and is heard, too, much more in the expiration than in inspiration. In 
collapse there is also heard, unlike either pneumonia or pleurisy, an abun- 
dant subcrepitant rale. To add to these differences, it is proper to say 
that, in cases of pneumonia and pleuris}^, the course of the disease is much 
more regular, and the special symptoms so well marked as to leave no 
doubt as to the real nature of the attack. 

Prognosis. — The prognosis of collapse must depend, in great measure, 
on two circumstances — the amount of bronchitis which accompanies it, 
and the constitutional state of the child. When it occurs during the 
course of extensive bronchitis, as shown by a great abundance and ex- 
tent of the bronchitic rales, it must add greatly to the danger of that dis- 
ease ; and if, at the same time, the child be weak and debilitated, either 
from causes long previously in action, or from the severity of the present 
attack, the risk to life is very great indeed. Collapse is dangerous, also, 
but far from necessarily fatal, in subjects in whom its chief cause has 
been simple debility. The possibility and the probability of recovery 
will depend on the hygienic conditions to which the child is exposed, the 
degree of vital strength it is likely to inherit from its parents, the extent 
of the collapse, as indicated by the severity of the thoracic symptoms, 
both rational and physical, and the effects of treatment. "When the sub- 
ject can be placed under favorable hygienic conditions, when it has in- 
herited from its parents a good and vigorous hold on life, and when the 
symptoms of collapse are not very violent, a proper and rational treat- 
ment will in all probability save it, while, under opposite circumstances, 
the chance of recovery would be very small, if there were any. 

Treatment. — The treatment of collapse, or post-natal atelectasis, must 
vary somewhat in different cases. One general rule will apply, however, 



TREATMENT. 151 

to all ; that is to employ a sustaining and strengthening system of medi- 
cation, to the exclusion of all exhausting means. 

In cases which are entirely, or almost entirely, independent of bron- 
chitis, the most important measures to be attended to are the regulation 
of the temperature in which the child is kept, of the clothing, and of the 
diet, the use of mild stimulants and of tonics, and the external employment 
of revellents. The child ought to be kept in a warm, even temperature, 
one from T0 C to 75°; it should be clothed in soft flannels, and its diet 
ought to be nourishing and strengthening. If at the breast, we should 
be sure that the milk is of a good quality, and that the nurse has an 
abundant flow. If weaned recently, it ought to have, if possible, a wet- 
nurse, and so also if it be supposed that the mother has too little milk, 
or that this is not perfectly healthy. If permanently weaned, the diet 
should be so arranged as to give to the child what is at the same time 
easy of digestion and nutritious. In a severe case, coming on suddenly, 
the most suitable internal remedies are brandy, in small doses, frequently 
repeated, Huxham's tincture of bark, the spiritus Mindereri or the aro- 
matic spirits of hartshorn, and small doses of quinine or extract of cin- 
chona. In slower and more chronic cases, we must depend on a well- 
selected and nutritious diet (and food ought to be given almost by force, 
or at least it should be urged strongly on the child), on warm clothing, 
and on the use internally of brand}-, quinine, the citrate of iron and 
quinine, pure metallic iron, the iodide of iron, Huxham's tincture of bark, 
or some such remedy. In sudden cases, the best revellents are the fol- 
lowing : mustard weakened by admixture of flour or Indian meal, and 
applied once in three or four hours; a plaster made of suet or simple 
cerate grated over with nutmeg; or liniments composed of ammonia, 
spirit of turpentine, or oil of amber, mixed with sweet oil. In chronic 
cases, the Burguncty pitch, or compound Galbanum plaster, made some- 
what weaker than those used for adults, should be applied over the front 
and back of the chest, or we may rub the thorax twice a day with any 
ordinary ammonia liniment, made, if necessary, rather more irritating 
than usual by the addition of some oil of monarda. The daity use of a 
gentle emetic of ipecacuanha has been recommended, and supposed to 
prove useful, by emptjdng the bronchia of their secretions, and also by 
the fact that its operation induces several deep inspirations, and in that 
mode promotes the better performance of the respiratory act. We have 
never employed the emetic except in cases accompanied with a good deal 
of bronchitis and consequent accumulation of mucus in the air-tubes, and 
not then when the prostration was very great. In fact, the operation of 
any emetic is sometimes productive of so much exhaustion of the strength, 
as to cause us to hesitate in prescribing a remedy of that class ; though 
we can fully understand that the act of vomiting, if not followed by too 
much prostration, could scarcely fail to prove beneficial in collapse, by the 
strong efforts at breathing which it gives rise to, and also by the succus- 
sions it must impart to the lungs through the medium of the diaphragm. 

In cases of collapse occurring in the course of, or towards the termina- 
tion of severe bronchitis, the treatment must resemble a good deal that 



152 COLLAPSE OF THE LUNG. 

which we have just described as proper for the same condition, when it 
exists unassociated. or associated only to a slight extent, with that dis- 
ease. When the symptoms of imperfect expansion appear towards the 
termination of. or after the patient has partially recovered from bron- 
chitis, and when of course the strength is more or less reduced by the 
severity of the previous acute sickness, and also perhaps by the necessary 
measures of treatment, the case ought to be managed very much in the 
same way as has just been recommended for those in which the collapse 
was caused chiefly by exhaustion, and less by the presence of obstructing 
secretions in the bronchia. Nourishing, but very light and digestible 
food: mild stimulants, as small quantities of brandy or wine-whey: the 
bitter tinctures, iron, or quinine, with counter-irritants to the surface of 
the chest, warm clothing, and repose, constitute the necessary and most 
reasonable remedies. When, en the contrary, the atelectasial condition 
supervenes in the midst of extensive and severe bronchitis, we are called 
upon to treat at the same moment two morbid states, one consisting of 
active inflammation, and another of want of power in the muscles of 
respiration to force the atmospheric air through the secretions which are 
obstructing the air-passages. Under these circumstances, there is almost 
always associated with the bronchitis, as we shall find when we come to 
treat of that disease, more or less intense congestion of the collapsed 
portions of the lungs. We must employ, therefore, such remedies as 
tend to modify the inflammation of the bronchial mucous membrane, and 
diminish thereby the amount of secretion poured into the air-passages : 
such as may serve to expel mechanically those secretions ; and those which 
shall unload the congested lung of its excess of blood, always taking care, 
in our selection of the agents to accomplish these ends, to choose those 
which are the least perturbative and exhausting. To moderate the in- 
flammation of the bronchial mucous membrane, we may employ dry cup- 
ping, or, if the patient be not too much reduced, wet cupping or leeching, 
but these latter with great moderation. For the same purpose, and with 
a view also to unload the congested parts of the lung, counter-irritation 
is very important, and the best mode of effecting this is by the repeated 
application of dry cups, or of mustard poultices, consisting of one-third 
mustard to two-thirds Indian meal or flour, and by mustard foot-baths. 
These poultices ought to be applied first to the dorsum and then to the 
front of the chest, once in every three or four hours, and they should be 
made large enough to cover a considerable portion of the thoracic walls. 
Counter-irritation, assiduously made use of, is, we believe, one of the 
most, if not the most effectual means of treatment in the case. Emetics 
ought to be given twice a day, or even three times, if they do not reduce 
the strength too much. The best are those which operate with the leas: 
subsequent prostration, such as ipecacuanha or alum. When they are 
found to exhaust much, and to increase thereby the labor of breathing, 
their use must be suspended. 

After emetics, or when these cannot be used, the remedies from which 
we have obtained the greatest benefit are the liq. ammon. acetat.. and 
seneka, either in decoction or syrup, combined sometimes with small 



PNEUMONIA. 153 

quantities of opium. To a child two years old we should give twenty 
drops of the acetate of ammonia solution, with ten of the syrup of seneka, 
or with a teaspoonful of decoction of seneka, eveiy two hours. When 
the cough is paroxysmal, painful, and harassing, about ten drops of pare- 
goric, half a drop or a drop of laudanum, or from four to six drops of 
solution of morphia, may be added to each dose of the spiritus Mindereri 
and seneka. The opiate ought to be continued until the cough and rest- 
lessness diminish, and then be suspended. In all these cases, there should 
be no hesitation in giving small quantities of brandy or wine-whey, when- 
ever the symptoms of prostration are so marked as to indicate immediate 
danger ; when the pulse is very rapid and small, when the skin is cool 
or pale and bluish, and when the general aspect of the patient, and the 
convulsive and labored character of the breathing, show that the muscular 
strength of the child is scarcely sufficient to carry on the function of 
respiration. 



AKTICLE II. 



PNEUMONIA. 



Definition; Synonymes; Frequency; Forms. — The term pneumonia 
is now, by universal consent, applied only to inflammation of the par- 
enchymatous structure of the lungs. It is often called, in this country, 
catarrh-fever, lung-fever, or inflammation of the lungs. 

It is one of the most frequent, and, therefore, one of the most impor- 
tant of the acute diseases of childhood. Dr. West, in a paper on the 
pneumonia of children (Brit, and For. Med. Bev., April, 1843) informs 
us that the English tables of mortality show pneumonia to be the cause 
of a larger number of deaths in childhood, than any other disease, with 
the exception of the exanthemata. From the third report of the Reg- 
istrar-General, he quotes the facts, that of all the deaths in the metropoli- 
tan districts under fifteen years of age, 13.6 per cent, were from pneu- 
monia, 13.0 per cent, from convulsions, and 5.4 per cent, from hydro- 
cephalus. He obtained nearly similar results from an examination of the 
returns from Manchester, Liverpool, and Birmingham. 

In this city it appears from the bills of mortality that the deaths from 
this disease are strikingly below the percentage calculated b}- Dr. West. 
Thus, during the past seven years, the total mortality from all causes 
(excluding still-born children) was, at all ages, 105, 185 ; under fifteen 
years of age, 50,151 ; and under five years, 43,322. The total mortality 
from pneumonia during the same period was, at all ages, 5561, or 5.26 
per cent, of the entire mortality ; under fifteen years, 2985, or 5.95 per 
cent, of the mortality under that age; and under five years, 2746, or 
6.33 per cent, of the mortality under that age. During the same series 
of years, the total mortality from bronchitis was, at all ages, 969, or less 
than 1 per cent, of the entire mortality; under the age oi' fifteen years, 



154 PNEUMONIA. 

509, or 1.01 per cent, of the mortality under that age ; and under the age 
of five j-ears, 495 or 1.14 per cent, of the mortality during the first five 
years of life. 

Any one who will study with attention the various doctrines in regard 
to pneumonia and bronchitis that have been set forth in the different 
works on the diseases of children, will most assuredly acknowledge that 
there are few diseases about which there has prevailed so much diversity 
of opinion as to the real nature of the lesions forming the essential an- 
atomical characters of the disorder, and, as a consequence of this, so 
much doubt as to the proper mode of classif3 T ing and describing them. 
From the time of the appearance of the works of M. Valleix, M. Barrier, 
Dr. Gerhard, and especially that of MM. Billiet and Barthez, up to the 
moment of publication of the essay of MM. Legendre and Bailly (referred 
to in the article on atelectasis), it was commonly believed that inflamma- 
tion of the parenchyma of the lung exhibited in children very different 
characters in the majority of the cases, from those which marked the 
pneumonia of the adult. Two principal forms of the disease were there- 
fore described by most writers, — the lobular and the lobar. The former 
was supposed to be almost peculiar to children, and to occur only on 
rare occasions in adults ; the latter was held to resemble, in almost every 
respect, the pulmonic inflammation of the adult. Moreover, lobular pneu- 
monia was generally believed to be by far the most common form assumed 
by the inflammation in children under five years of age, whilst lobar pneu- 
monia was thought to be comparatively rare under the age mentioned. 
Besides these two chief varieties of pneumonia, two others have been 
described under the names of vesicular and marginal pneumonia, while 
to yet another MM. Killiet and Barthez applied the title of carnijication. 

The researches of MM. Legendre and Bailly have caused a great revo- 
lution in the views of a large number of medical observers and writers. 
These authors first pointed out (as stated in the article on atelectasis) 
that a very large proportion of the cases previously described under the 
titles of lobular pneumonia, generalized lobular pneumonia, pseudo-lobar 
pneumonia, marginal pneumonia, and the carnification of MM. Rilliet 
and Barthez, were in fact cases of bronchitis variously associated with 
congestion and collapse of the tissue of the lung. Thej^ themselves de- 
scribed these supposed different forms of pneumonia under the title of 
catarrhal pneumonia. But, though they were opposed to the opinion of 
lobular pneumonia being a true inflammation of the lung, they did not 
assert that children were not subject, like adults, to regular inflammation 
of the pulmonary parenchyma. They described, in fact, as nearly all 
others have done, a lobar pneumonia, which exhibits the same anatomi- 
cal characters, and veiy nearly the same train of symptoms, both rational 
and physical, as the pneumonia of adult life ; and a partial pneumonia, 
in which the inflammation, instead of invading a large part of a lobe or 
a whole lobe, attacks isolated small portions of the parenchyma, so as 
to present an appearance of nodules of inflammation scattered here and 
there through the healthy tissue. 

Since the publication, in 1844, of the views arrived at by MM. Legen- 



FORMS — PREDISPOSING CAUSES. 155 

dre and Bailly, numerous other observers have repeated and continued 
their researches, but with very different results. Some have adopted their 
opinions entirely, others in part, while a few still adhere tenaciously to 
the old doctrines. Amongst those who now believe that lobular pneumo- 
nia in its different forms is in fact bronchitis with collapse of the lung- 
tissue, and not inflammation of the pulmonary parenchyma, the most im- 
portant are Drs. "West and W\ T. Gairdner (loc. cit.), MM. Hardy and 
Behier {Pathol. Int., t. ii, p. 529, et seq.), MM. Killiet and Barthez, in 
their second edition, and Dr. Fuchs (Brit, and For. Med.-Chirurg. Rev., 
July, 1850, p. 154, et seq.). Amongst those who oppose the new views, 
we ma}* mention the names of M. Bouchut and those of the authors of 
the Compendium de Medecine Pratique. We would refer any one who 
desires to study this matter as treated by English hands to the essay 
On the Pathological Anatomy of Bronchitis, and the Diseases of the Lung 
connected with Bronchial Obstruction, by Dr. W. T. Gairdner, of Edin- 
burgh. It is decidedly the best English work on the subject we have 
seen, for it treats not only of atelectasia in children, but contains yet 
more numerous observations upon the same condition as it occurs in 
adults. The second edition of MM. Billiet and Barthez is also very full 
on this subject, those authors adopting in great measure, as above stated, 
the views of MM. Legendre and Bailly. 

Our own opportunities for investigating this interesting subject by post- 
mortem examination have been comparatively few, so that we have been 
obliged to form our conclusions in regard to it chiefly from a stud}^ of the 
researches of others, and from a comparison of the symptoms which we 
have observed during life in the different pulmonary affections of chil- 
dren, with those researches, and with the results we have obtained from 
the few autopsies that we have been able to make. Assisted by these 
combined means of forming a conclusion upon the subject, we have been 
led to the belief that the former method of dividing the pneumonia of 
children into the two forms of lobular and lobar is incorrect, and we have 
determined to substitute for the term lobular that of partial, which is the 
one employed by M. Legendre and also by Dr. Alois Bednar (Die Krarik- 
heiten der Neugebornen und Sduglinge, Dritter Thiel, Wien, 1852, p. 65), 
while we shall describe the other -form of the disease under its usual title 
of lobar. Of these two forms, the latter is much the most frequent, 
though it was formerly thought that the lobular was more common than 
the lobar variety, simply from the fact that bronchitis attended with lob- 
ular collapse (the condition heretofore almost alwa} T s described as lobular 
pneumonia) is much oftener met with in children than true pneumonia, 
either lobar or partial. 

Predisposing Causes. — It is gen erally believed that pneumonia is most 
apt to occur in the course of other affections. This is certainly true in 
regard to the disease as it prevails in hospitals, and probably amongst 
the poorer classes of society also. MM. Billiet and Barthez state thai ot 
two hundred and forty-five cases observed by themselves, only fifty-eight, 
or a little less than a fourth, occurred in children previously in good 
health. The proportion of secondary cases is much smaller in private 



156 PNEUMONIA. 

practice, since of fift} T -one cases of well-marked pneumonia, observed by 
ourselves, in which this point was noted, only six were secondary. No 
doubt one cause of this apparent discrepancy between the authors men- 
tioned above and ourselves, is the fact that we have left out of considera- 
tion all the cases in which the pneumonic sj-mptoros were not entirely 
clear, thus putting aside a number of cases which the}^ would have classed 
as lobular pneumonia, but which we prefer to regard as examples of bron- 
chitis with collapse. Age forms a strong predisposing influence. Of the 
two hundred and forty-five cases above quoted, one hundred and seventy- 
two occurred under five years of age. Dr. West (Joe. cit.) sa} T s that during 
the first five } T ears of life, the cases of pneumonia were in the proportion 
of 10.3 per cent, to the total of diseases, while in the succeeding five years 
the} T were in the proportion only of 1.3 per cent. The mortality bills of 
this city exhibit the same marked excess in the proportion of deaths from 
pneumonia under five years of age, as compared with the ensuing years. 
We have already seen that the proportion during the first five j-ears of 
life is 6.33 per cent, of the entire mortality under that age ; while during 
the ensuing ten years the deaths from pneumonia form but 3^- per cent. 
of the total mortality during that period of life. These statements do 
not agree with our own experience in private practice, since of fifty-five 
cases that we have seen in which this point was noted, twenty-eight oc- 
curred under five, and twent3 T -six between five and eleven years of age, 
showing that the frequency in the first five and the subsequent six years 
of life is very nearly the same. True pneumonia is less frequent in private 
practice in the first two, than in the succeeding years of life. 

Sex. — A larger number of cases occur in boys than girls. The excess 
is probably not more, however, than may be accounted for by the prepon- 
derance of male over female children. Of fifty-five cases in which we 
have noted the sex, thirty occurred in boys, and twenty-five in girls. 

Constitution. — It is doubtful whether constitution has much or any in- 
fluence upon the liability to the disease. Dr. West says that weak health 
is not a predisposing cause, according to his experience. We are con- 
vinced that it attacks strong and vigorous children more frequently than 
those of more delicate constitution. In children of feeble health and weak 
stamina, the very same causes which produce pneumonia in the robust, 
give rise to bronchitis. 

Season. — The disease is most prevalent during the winter and early 
spring months, as will be seen from the accompanying table, in which is 
shown the mean monthly mortality in Philadelphia, for the past seven 
years, from this disease, as well as from bronchitis. From this it will be 
seen that in December, January, February, and March (and the same is 
very nearly true of April also), the deaths from these diseases are three 
times as numerous as in August. 



INFLUENCE OF SEASON — ANATOMICAL LESIONS, 



157 



Mean mon 


thly 


Mean total 


Mean monthly 




mortality for 7 years, 


mortality from all 


percentage for 7 


Mean monthly 


from Pneumonia 


causes (includ- 


years, from 


temperature 


and Bronchitis. 


ing still-born) 


Pneumonia and 


(F.) for 7 years. 






for 7 years. 


Bronchitis. 




Pneumonia, 
Bronchitis, 


. 46 
. 6.29 


1296.71 


3.54 
0.48 


30.87° 


Pneumonia, 
Bronchitis, 


. 45.57 
. 8.43 


1206.71 


3.76 
0.69 


33.89° 


Pneumonia, 
Bronchitis, 


. 48.57 
. 7.14 


1344.29 


3.61 
0.53 


40.85° 


Pneumonia, 
Bronchitis, 


. 41.57 
. 5.71 


1281.14 


3 24 
0.44 


52.27° 


Pneumonia, 
Bronchitis, 


. 34.76 

. 6.57 


1234.29 


2 81 
0.53 


62.77° 


Pneumonia, 
Bronchitis, 


. 26.14 
. 5.00 


1178.14 


2.21 
0.42 


71.97° 


Pneumonia, 
Bronchitis, 


. 24.14 
. 4.00 


1837.00 


1.31 
0.21 


77.71° 


Pneumonia, 
Bronchitis, 


. 20.14 

. 3.00 


1825.43 


1.10 
0.16 


76.62° 


Pneumonia, 
Bronchitis, 


. 14.57 
. 5.29 


1215.43 


1.19 
0.43 


68.31° 


Pneumonia, 
Bronchitis, 


. 22.43 
. 5.43 


1218.14 


1.84 
• 0.44 


56.30° 


Pneumonia, 
Bronchitis, 


. 28.86 
. 5.71 


1052.14 


2.74 
0.54 


46.68° 


Pneumonia, 
Bronchitis, 


. 39.57 
. 8.14 


1191.00 


3.32 
0.58 


34.74° 



Months. 

January, . . 
February, . 
March, . . . 
April, . . . 
May, .... 
June, .... 
July, .... 
August, . . 
September, . 
October, . . 
November, 
December, . 



We have also placed in parallel columns the mean percentage of mor- 
tality from these two diseases, and the mean monthly temperatures, in 
order to show the marked correspondence between the coldness of the 
weather and the frequency of pneumonia and bronchitis. It is evident, 
however, that there is another element, beside the mere temperature, in 
determining their frequency, since, in both February and March, more 
deaths occurred from these causes than in January, although this latter 
is the coldest month of the year. The additional element is undoubtedly 
to be found partly in the sudden atmospheric changes, and damp, raw 
days which are so frequent, in both February and March, in our latitude, 
and partly in the impaired vitality found in many children, as the result 
of the intense cold of the preceding months. 

Previous Diseases. — It is apt to occur as a complication of all the dis- 
eases of children, and most frequently in measles, pertussis, typhoid 
fever, enteritis, and bilious remittent fever. 

Exciting Causes. — The continued action of some of the predisposing 
causes must be regarded as the exciting cause in the majority of the 
cases. External violence, as a severe fall, or a blow upon the chest, will 
sometimes act as an exciting cause. The action of cold is almost always 
alleged to be the immediate cause of the attack. M. Grisolle states that 
it is impossible to determine the exciting cause in more than a fourth of 
the cases, and that in nearly all of these it is cold. 

Anatomical Lesions. — Lobar- pneumonia in the child is marked by the 
same physical characters as in the adult. The three stages of the intlam- 



158 PNEUMONIA. 

mation — engorgement, red hepatization, and gray hepatization — exhibit 
the same alterations of the tissues as in adult life. Moreover, the three 
stages occur with about the same frequency in early as in later life. Dr. 
West (loc. cit, 2d ed., p. 189) shows that the third stage occurs ver} T nearly 
as often in children as in adults, he having met with it in the former in 
the proportion of sixty-eight per cent., while M. Grisolle found it in 
sevent} T -two per cent, of the latter. The chief difference in the disease, 
as it exists at the two ages, consists in the more frequent coexistence of 
all three of the stages in the young subject. 

In the first stage, or that of engorgement, the affected portion of lung 
is distended, so that it does not collapse in the same proportion as the 
healthy portions, when the thorax is opened. It is heavier than usual, 
so that it sinks somewhat in water ; it is of a brownish-red color ; it pits 
upon pressure, and crepitates less than healtlry lung, the crepitation being 
observable only here and there. The natural degree of cohesion between 
the tissues is somewhat diminished, so that the diseased portion is much 
less tough and elastic, and more soft and friable than it ought to be. 
When cut into, a large quantity of frotlry, and more or less deeply-tinged 
sanguineous fluid escapes. 

In the second stage, or that of red hepatization, the lung is increased 
in volume, so that it continues to fill the side of the chest after that cavity 
is opened ; it is dense and hard, has ceased entirely to crepitate, from the 
fact of having become completely impermeable to air, and sinks rapidly 
when thrown into water. Externally, the diseased portion is of a deep 
red color, while internally the same color is observed, but often of such 
different shades as to give to a cut surface a marbled aspect. The cohe- 
sion between the tissues is, in this stage, much less strong than in health 
or in the first stage of the disease; the finger penetrates the lung with 
some ease, and the texture can be crushed between the finger and thumb. 
When cut into, there escapes a non-aerated and reddish fluid, which is 
much less abundant than in the first stage. The most important feature 
of red hepatization is, however, the granular character of an incised sur- 
face. This granular appearance is produced by the presence of numerous 
minute flat granular elevations, which seem to consist of effused matter 
that has been thrown out in the air-vesicles. It is best seen by examining 
a torn surface of the lung. 

In the third stage, or that of gray hepatization, the lung continues to 
exhibit the same volume, density, impermeability to air, and consequent 
total absence of crepitation, as in the second ; but the process of soften- 
ing has made still further progress, so that a portion of the lung may be 
squeezed with the greatest ease between the finger and thumb into a pulp. 
The color has now changed from deep-red to a dirty light-gray, or a pale 
straw-3'ellow. When incised, the surface still presents a granular appear- 
ance, but the granules are more irregular and flatter. The diseased por- 
tions are now infiltrated with a puruloid fluid, which escapes in consider- 
able quantities in the form of a j^ellowish-gi^ liquid, whenever the lung- 
is cut into. 

The anatomical lesions, which characterize partial pneumonia, occur 



ANATOMICAL LESIONS. 159 

under two conditions. In one the alterations are exactly the same as 
those of the lobar form, the only difference between the two being that, 
in the partial form, the hepatization affects distinct patches of the pul- 
monary substance, producing, therefore, hard nodules of hepatization, 
scattered through healthy tissue. These nodules are irregular in form, 
and imperfectly circumscribed, but present, like the lobar form, the three 
stages of the inflammation, — engorgement, red hepatization, and gray 
hepatization. The second variety of partial pneumonia is characterized 
by patches of hepatization, varying in number from fifteen to thirty, and 
in size from that of a hemp-seed to that of a pigeon's egg^ which are more 
or less spherical in shape, hard to the touch, and exactly limited. M. 
Legendre states that these hepatized points become transformed into a 
grayish, rough, and uneven substance, of a fibrous appearance ; a change 
which takes place at different points of the diseased mass, sometimes in 
the centre only, sometimes in their whole extent, and at others on their 
circumference. 

Abscesses are not very uncommon in the pneumonia of children. They 
occur as a result of the third stage of the disease, so that in the same lung 
may be observed the first, second, and third stages of the inflammation, 
and abscesses. The cavities of the abscesses are generally circular, some- 
times oval, and they measure from half a line to an inch or more in diam- 
eter. Sometimes the abscess is multilocular, each of the purulent cavities 
being partially separated from its neighbor by a wall of hepatized tissue. 
They are found in various parts of the lung, but seem disposed, generally, 
to approach the surface of the organ. When the latter event happens, 
adhesive inflammation between the pulmonary and costal pleura usually 
takes place ; but should this fail to occur, the abscess ruptures into the 
pleural sac, and produces pneumothorax. MM. Rilliet and Barthez met 
with two examples in their autopsies, in which this accident had occurred, 
and they report another case in which it occurred during life, and in 
which the child recovered. We have met with two cases of pneumothorax 
ourselves, produced in the same way. One occurred in a boy eleven 
years old, during an attack of secondary pneumonia complicating a severe 
bilious remittent fever. The patient recovered entirely, after a most vio- 
lent illness. The other occurred in a very young child and proved fatal. 

We are desirous, before closing our remarks on the anatomical lesions 
of the disease under consideration, of drawing attention to the subject of 
simple non-inflammatory congestion of the lung, for the reason that the 
latter has no doubt, especially when associated with collapse of the pul- 
monary tissue, been frequently mistaken for pneumonia. 

Congestion of the lung occurs either in the lobular or lobar form, the 
distinction between the two being the same as that between lobular and 
diffused or lobar collapse. When lobular, the lung presents, generally 
along the posterior edge of the organ, disseminated lobules, distinctly 
circumscribed by the interlobular cellular septa, which are rather protube- 
rant than depressed, more friable, and of a lighter purple color than col- 
lapsed lobules, and which afford, when squeezed, a considerable quantity 
of frothless bloody fluid. In very young infants, the congestive disposi- 



160 PNEUMONIA. 

tion often assumes the lobar or diffused form, and is supposed by M. 
Legendre to have frequently been taken for pneumonia. In this variety 
of congestion, the affected portion of the lung is increased in size, and is 
distended and gorged with fluids. The color of the congested part varies 
from a light to a dark purple, or almost blackish tint. The cohesion of 
the lung is also variable, the differences depending on the degree of the 
congestion. When this latter is very great, the part is very friable, while 
it is much less so under the opposite condition of things. Though the 
lung is harder in this state than natural, it still retains a certain degree 
of flaccidity which does not exist in true hepatization. Pressure causes 
an abundant exudation of blood and serosit} 7 from a cut surface, and the 
latter, instead of being granulated, as is always the case in hepatization, 
is smooth and even. Neither does the lung exhibit any granulations 
when it is torn. Lastly, inflation distends all the vesicles, and gives to 
the condensed parts their natural lightness, and their rosy color, though, 
be it remarked, the development of the affected parts under the opera- 
tion is not complete and entire as in collapse, in consequence, no doubt, 
of the large amount of blood they contain. 

Inflation of the lung after death has been much employed of late, as 
any one who has read the previous remarks on atelectasia must have seen, 
as a means of distinguishing between pneumonia and collapse. It was 
there stated that, whilst inflation distended, and restored more or less 
completely to their natural condition, parts of the lung that were merely 
collapsed, it failed almost entirely to have any effect on parts of the lung 
affected with true pneumonia. It is easy to understand wiry inflation 
should fail to exert much effect on inflamed lung, at least when the dis- 
ease has reached the state of hepatization. In fact, the tissues compris- 
ing the lung are glued together and hardened b} r a deposit of plastic 
lymph, poured out chiefly on the inside of the air-cells, so that it becomes 
impossible to force the air into the midst of the agglutinated structures. 
In the first stage of pneumonia, that of congestion, inflation will distend 
in some degree the affected portions, but, in the second and third stages, 
not even the strongest force has any effect on the impermeable vesicles. 

Lobar pneumonia is stated by most authorities to be generally confined 
to one lung, and such has been our own experience in regard to it, since 
of 56 cases in which its location was carefully determined, it was uni- 
lateral in 52, and double only in 4. It is much more common on the 
right than left side, according to most writers. In the 52 cases just re- 
ferred to, the distribution was nearly equal, the disease being seated 29 
times on the right side, and 23 times on the left. It attacks the lower lobe 
much more frequently than the upper. Of 51 cases in which this point 
was determined, the upper lobe was the part affected in 20, while in 31 
the base of the lung was the seat of the disease. Of the 20 cases of in- 
flammation of the upper lobe, in 13 it was seated on the right, and in 1 
on the left side. Of 31 cases occurring in the lower lobes, 15 were on 
the right, and 16 on the left side. In the 4 cases of double pneumonia, 
the inflammation attacked the lower lobes of both lungs in one ; in one 
the postero-inferior part of both upper lobes was especially involved ; 



ANATOMICAL LESIONS. 161 

while in the two others it attacked first the base of the left lung, and 
afterwards the summit of the right. 

The statements just made as to the seat of the pneumonic inflammation 
in the cases that have come under our own observation, do not, we are well 
aware, agree exactly with the experience of other observers. Dr. West, 
for instance, found (loc. cit., p. 1*90) that double pneumonia preponderated 
greatly, in early life, over those wherein only one lung suffered. This, 
it will be observed, is widely different from the result of our experience, 
and it is also directly opposed to that of MM. Rilliet and Barthez, Rufz, 
and Barrier. M. Barrier, in fact, cites (Mai. de L'Enfance, t. i, p. 286) 
144 cases of lobar pneumonia as having been observed by the authors 
just mentioned, and by himself, and of these only 15 w T ere double. Our 
results in regard to the frequenc}' of double lobar pneumonia agree, there- 
fore, with those of the authors last mentioned, but they differ as to the 
relative frequency with which the two lungs are attacked. Thus, in our 
cases, the inflammation occurred with nearly equal frequency in the two 
lungs, whilst of 129 cases of unilateral pneumonia observed by the above 
authors, 84 were seated in the right, and 45 in the left lung. These 
writers state, as most others do, that pneumonia of the lower lobe is more 
common than that of the upper lobe. This tallies with our observations, 
but, as it seems to be a general opinion in the profession, that inflamma- 
tion of the summit of the lung is rare in comparison with that of the base, 
we wish to call attention again to the fact stated above, that of 51 cases, 
in which we ascertained accurately the seat of the disease, it was in the 
upper lobe in 20, and in the lower in 31. 

It was formerly supposed that bronchitis was an exceedingly frequent 
accompaniment of pneumonia, and there is no doubt that such is really 
the fact in a much larger proportion of the cases that occur in children, 
than of those that occur in adults. But, since the discovery of the nature 
of the anatomical alteration, which we have described under the title of 
collapse or atelectasis, it has become clearly evident that one reason why 
it was thought that bronchitis so generally accompanied the pneumonia 
of children, has been that a large number of cases, heretofore classed as 
pneumonia, were in reality cases of bronchitis attended w r ith collapse. It 
has been shown, indeed, in the preceding pages, that there is good reason 
to believe that a very large majority of the cases hitherto described as 
lobular pneumonia, ought to be classed under the head of bronchitis. 
Now, these cases are precisely those in which bronchitis has been found 
to occur so constantly, and to form so large a portion of the disease, and 
they, moreover, have always been stated to be of much greater frequency 
than cases of lobar pneumonia. .If, however, we conclude to regard what 
was formerly called lobular pneumonia, as bronchitis with collapse, and 
to restrict the title of pneumonia to the cases in which there is a true 
hepatization of the lung, we shall have left only lobar pneumonia, which 
is not at all a rare affection, and partial pneumonia. Now, in the lobar 
pneumonia of children, as in that of adults, bronchitis docs not usually 
exist to any very considerable extent, and we may state, therefore, that, 
though bronchitis exists to a greater or less extent in most of the pneu- 

11 



162 PNEUMONIA. 

monic cases of children, it is in a much less severe degree than was at 
one time supposed. 

"When bronchitis is present it varies from simple increased vascularity 
with augmented mucous secretion, to intense congestion with purulent or 
pseudo-membranous secretion. 

Pleurisy is a frequent complication, as it is found to exist in about 
half the cases. 

Emphysema is another common complication. It generally occupies 
the upper part of the lung, or its free edge, and is found most strongly 
developed in the lung which presents the greatest amount of inflamma- 
tion, or in both, when both are inflamed. Its degree depends on the ex- 
tent of the pulmonary inflammation and bronchitis, and the severity of 
the dyspnoea. The vesicular form is much more frequent than the inter- 
lobular. 

Symptoms; Sketch of the Disease; Course. — In order to present a 
faithful account of the disease, a general sketch of the symptoms will 
first be given, after which the most important ones will be considered 
separately under the head of particular symptoms, so that the reader may 
first obtain a notion of the course of the disease, and then become inti- 
mately acquainted with its details and peculiarities by reference to the 
remarks on each particular s} T mptom. 

True pneumonia, with well-marked hepatization, is not, according to 
our experience, a common affection in j'oimg infants in private practice, 
since out of fifty cases of the disease that we have met with in children, in 
which we have noted this point, only two occurred in infants within the 
first, and three in the second year. Of the two cases within the year, one 
occurred in a child six weeks old, and the other in one seven months. 

In new-born children, and those still at the breast, pneumonia very gen- 
erally begins with more or less marked symptoms of bronchitis, though 
in some instances it commences suddenly, as it does in adults, without 
any previous sign whatever of bronchial inflammation. When it occurs 
during an attack of bronchitis, the symptoms which belong to the pneu- 
monic inflammation will, of course, have been preceded by those which 
depend on the disease of the bronchial ■ mucous membrane. In these 
cases, the development of the pneumonia will be indicated by an aggra- 
vation of the general symptoms, by an increase of the oppression, by the 
fact that the cough and breathing both become more painful than before, 
and by the occurrence of the physical signs peculiar to pneumonia, or, 
in other words, by the symptoms which depend upon and mark a state of 
inflammation of the parenchyma of the lung. Of these we shall now give 
an account. 

When pneumonia appears as a primary affection in young children, 
without preceding bronchitis, as sometimes undoubtedly happens, though 
much less frequently than in children over five years of age, and especi- 
ally than in adults, the attack is usually sudden. The first symptoms 
observed are restlessness, peevishness, disposition to cry, a diminished 
appetite for the breast, and feverishness. These symptoms are most 
marked in the evening and night. From the very first, or by the second 



SYMPTOMS. 163 

day at least, cough is heard, and careful examination of the breathing 
will show that it is somewhat hurried. The cough is dry, short, and hack- 
ing, at first, and not very frequent, but it soon becomes louder, fuller, 
more straining, and especially it becomes painful. The fact that it is 
painful may always be ascertained b}' watching the motions of the child, 
its cry, and the expression of the face. We can always perceive, even in 
an infant, a disposition to restrain the cough, to smother it, a struggle to 
make it short and sudden, when it causes sharp pain. At the moment of 
the cough, too, a marked expression of pain, a kind of sudden grimace 
or twisting of the features, ma}' always be observed, which is accompa- 
nied or followed instantly by a loud, sharp cry, or a spell of crying. This 
grimace of pain, with the accompanying cry, we have never observed in 
their most characteristic form in simple bronchitis, but only in pneumonia 
and pleurisy. We have twice seen these sj^mp'toms so decidedly marked 
that the}' could not fail to have drawn any one's attention ; once in an in- 
fant six weeks old, who died of a most violent and extensive pleuro-pneu- 
monia, and again in a child thirteen months old, who died of pleurisy re- 
sulting in the formation of pure pus in the pleural sac. The nature and 
extent of the lesions were ascertained, in both cases, by examination after 
death. The presence of pain in the side is shown also by the fact that full 
inspirations, caused b}* changing the position of the child, and those which 
occur during fits of crying, occasion a sudden arrest or stoppage, so to 
speak, of the act of inhalation, which gives to the crying, and often also 
to the breathing, a sobbing character, while across the countenance passes 
at the same moment the expression of pain already referred to. The 
breathing, which is only slightly disturbed at first, soon becomes frequent 
and attended with more or less effort, and gives rise to an unusual play 
of the nostrils, a symptom which ought always to attract attention to the 
respiratory system as the seat of disorder. It interferes also with the 
act of nursing, so that whether the child takes the breast less frequently 
than usual, from want of appetite, or seeks it with greater avidity than 
common, from thirst, the act of sucking is attended with some difficulty. 
The infant seizes the breast for a few instants, then lets go in order to 
breathe more easily, and seizes it again ; or it drops the nipple suddenly 
and begins to cry, as though the act of sucking were painful from the 
necessity it begets of taking occasionally a fuller and deeper inspira- 
tion than usual. As a general rule, the bowels are torpid, while vomit- 
ing, which is rather unusual in older children, is quite common in young 
infants. 

When the disease is once established, whether it have been preceded by 
bronchitic symptoms, or occur as a primary affection, the symptoms are 
generally well marked, so as to leave but little difficulty in the recognition 
of the disorder. The child now loses all gaj-et}^ and cheerfulness, and 
becomes either dull and listless, or veiy restless, peevish, and trouble- 
some. Young infants generally lie quietly on the bed, or in the lap, 
merely fretting and crying when they cough, or when they are moved for 
any purpose, while children of several months old, and those in the second 
year, are usually very cross and restless, crying and screaming when any- 



164 PNEUMONIA. 

thing is done for them, and insisting upon being frequently moved from 
the cradle or bed to the lap, or from the lap to the cradle. As a general 
rule the} T are contented only upon the lap, always crying to get back when 
they are removed from it to the cradle or crib. In some instances, how- 
ever, they, like young infants, are quiet and dull, being content to lie 
still when placed in a comfortable position, and crying only after cough- 
ing, for the breast or drink, or when disturbed. 

A febrile reaction now displays itself in full force. The skin becomes 
hot and dry, and the pulse frequent, rising to 150 and 160, or higher, in 
infants, and to 140 and 150, or even 160, in those of several months old. 
The ctyspncea becomes more and more evident. The respiration rises to 
60, 70, 80, or even higher. In a case of pleuro-pneumonia at six weeks 
of age, we counted it at 128. The breathing is at the same time more or 
less labored and difficult, the alee nasi being seen to dilate spasmodically 
at each inspiration, while the motions of the chest, and especially those 
of the abdomen, are much stronger and more active than in healthful 
respiration. The cough is now more frequent than before, evidently pain- 
ful, and usually dry, though sometimes a slight degree of looseness may 
be detected in the sound which it occasions. 

Percussion now reveals manifest dulness over the seat of disease, which 
is usually the base, though not at all unfrequentty the upper region of one 
side. When the disease is double, wiiich is oftener the case, as alread} r 
stated, in children, than in adults, though not so often as has been sup- 
posed by some, the percussion will be dull of course over the affected 
region on each side. Together with the dulness of sound on percussion, 
and sometimes when this is faintly marked, there is an evident diminu- 
tion of the elasticity of the walls of the chest, and this becomes, there- 
fore, an important symptom, especially when dulness on percussion is 
absent. The dulness on percussion is not, indeed, so marked a symptom 
in infants as in adults, from the fact that the natural sonority of the chest 
is so much greater in the former than the latter. 

Auscultation reveals over the diseased part distinct and abundant fine 
subcrepitant rale ; but the crepitant rale or fine crepitation, which is the 
pathognomonic sign of pneumonia in adults, and which in them is rarely 
wanting, is absent in young children, or is heard only when they make 
deep and free inspirations. It is most apt to be heard in young children 
during the deep inhalations which they make just before crying, or during 
the act of crying. It is, therefore, much less constant, less strongly 
marked, and more fugitive, in children than in adults, and is, in the 
former, replaced in good measure by a fine subcrepitant rale. In connec- 
tion with these symptoms we always have more or less well-marked bron- 
chial respiration. This may be pure, which is rarely the case; it may be, 
as usually happens, associated with crepitant or subcrepitant rhonchus, or 
it may be heard only in the expiration. 

The symptoms above described show that the inflammation has reached 
the second stage, or that of red hepatization. After attaining this point, 
the disease usually remains stationar}^ for a few clays, and then either 
subsides, in favorable cases, by the resolution of the inflammation, or in 



SYMPTOMS. 165 

unfavorable cases, terminates fatally in this stage, or else passes into the 
third stage, and causes death bj" a more or less extensive suppuration of 
the lung. In favorable cases, which are said to be rare in very young 
infants, but more common in those several months old, and in the second 
year of life, the severity of the symptoms gradually diminishes. The 
fever subsides, the pulse becoming less frequent, and the skin cooler and 
less dry ; the breathing becomes easier and slower, and is attended with 
less pain ; the cough grows looser, less frequent, less difficult, and ceases 
to be painful ; the child begins to nurse without pain and with greater 
ease and facility ; the restlessness and fretfulness, or the somnolence, 
when that has been a marked s^ymptom, diminish, and the child becomes 
more placid, and sleeps quietly and tranquilly. The chest is now less 
dull than before on percussion ; the bronchial respiration begins to di- 
minish in intensity, and is very much masked by the subcrepitant rale, 
which becomes more and more evident, until at last it takes the place 
entirely of the bronchial breathing. The symptoms continuing to amend, 
the physical signs of the disease cease at length to be perceptible, the 
cough grows more and more loose and rare, the countenance becomes 
natural, the fever ceases, and convalescence is fully established. 

In unfavorable cases, death maj T occur rather suddenly in the second 
stage, without any very decided change in the physical symptoms, from 
exhaustion or from the supervention of collapse of portions of the lung- 
tissue. In these cases, the breathing becomes more and more rapid and 
labored, or it becomes slower than before ; the moist rales increase in 
abundance and extent, while the percussion often remains about the 
same ; the difficulty of sucking increases, so that the child, when put to 
the breast, attempts to draw but two or three times, and then lets go 
exhausted and distressed, or it makes no effort whatever ; the cough be- 
comes less frequent, but is still painful and difficult ; the skin grows pale 
and white, excepting about the face, hands, and feet, where it often as- 
sumes a bluish or c}'anotic hue ; the extremities, and often the face too, 
become cool ; the child becomes exceedingly restless, and then dull and 
perfectly quiet, or comatose, and death at last occurs from asphyxia. In 
another class of cases, which, however, are much more rare in very young 
children than in older ones, the disease passes into the third stage, or that 
of suppuration so-called. In such cases the febrile symptoms continue 
much longer than in those just now described ; the pulse becomes, and 
continues for several days together, very frequent and jerking ; the skin 
retains its heat and dryness, though it is often pale at the same time ; 
the child is usually excessively irritable and distressed; the breathing is 
rapid and oppressed, and often very irregular and uneven ; the dulness 
on percussion extends; the bronchial respiration becomes more distinct 
and is heard over larger surfaces, and is accompanied with less of the 
subcrepitant and crepitant rales; the cough is paroxysmal, painful, and 
often very harassing; the appetite is lost, and the sleep uneasy and often 
broken. These symptoms continue for several days, or a week or two, 
when they assume the same characters they exhibit in more rapidly fatal 
examples; that is to say, asphyctic phenomena develop themselves, and 



166 PNEUMONIA. 

the child dies exhausted and comatose, or perhaps convulsed, or after 
presenting for some hours, or a day, more or less severe spasmodic affec- 
tions of different muscles or of the extremities. 

The lobar pneumonia of children over two years, and especially of those 
over five years of age, exhibits most of the symptoms that characterize 
the same disease in adults. The chief differences to be noticed at these 
two periods of life, are the greater predominance of bronchitis in chil- 
dren, particularly in those under five or six years of age, which gives to 
the physical signs some peculiar features not observed in adults ; the 
frequent absence of expectoration, and, when it is present, certain differ- 
ences between it and that of adults ; certain peculiarities in the character 
and seat of the side-pain; and the existence in many instances of more 
marked and more dangerous nervous symptoms. 

The mode of onset is very different in different subjects. Generally, 
the attack begins with violent fever, increased frequency of breathing, 
more or less pain in the side, and short, dry cough. In such cases there 
is no difficulty in perceiving that the disease consists of some form of 
thoracic inflammation. But, in other instances, instead of this open and 
frank development, the disease comes on with symptoms which might 
well mislead any but a very attentive and competent physician, as to the 
true nature of the case. The most common cause of obscurity is a pre- 
dominance of the nervous symptoms, which often gives to the case very 
much the aspect of a meningeal inflammation. In an example that oc- 
curred to one of ourselves, a bo}' between six and seven years old was 
seized, after a short exposure during a ride on a raw and cold day, with 
violent fever, pain in both ears, severe frontal headache, and great sen- 
sibility to light when exposed to it. He was, at the same time, very 
drowsj T , sleeping nearly the whole day, but he could be roused when 
loudly and vehemently spoken to so as to answer a few questions and 
manifest great irritability, and, what was extremely suspicious of disease 
of the brain, when taken with the other sjanptoms, he vomited frequently. 
On the second day, the headache was very severe, the sensibility to light 
continued excessive, and he still vomited frequently, rejecting even water. 
The bowels were freely moved. There was up to this time no full cough, 
but only an occasional, and slight hacking, that scarcely attracted atten- 
tion. The respiration was accelerated, but there was no dyspnoea. No 
pneumonia could be detected, though carefully sought after. On the third 
day, the breathing was still more frequent, but not at all laborious ; the 
vomiting continued, but the other nervous phenomena had lost some of 
their intensity, and auscultation revealed well-marked bronchial respira- 
tion before and behind, over the summit of the right lung, while over the 
same regions the percussion was dull. We have met with several cases in 
which the onset of pneumonia was attended with nervous symptoms that 
made the diagnosis difficult and obscure. 

In other cases the onset of the disease is marked by sj^mptoms of gas- 
trointestinal irritation, or by such a degree of fever and disturbance of 
the nervous s} T stem, with absence of evident local phenomena, as to 
render the nature of the attack obscure and uncertain. In one, for in- 



SYMPTOMS. 167 

stance, occurring in a boy between four and five years old, and six weeks 
after recovery from measles, the attack began suddenly with violent fever, 
great restlessness and distress, vomiting, and distension of the abdomen. 
The case appeared to be one of gastro-intestinal disorder, as there was 
nothing to call attention to the thorax. On the second day, the S3 T mp- 
toms were much worse, the skin being hot and dry, and the pulse one 
hundred and sixty in the minute, and jerking. The child was drowsy 
and heavy; it was difficult to make him answer questions, and his answers 
were confused and unintelligible ; his movements were tremulous and un- 
certain. The tongue was dryish and very thickly coated, and he com- 
plained confusedly of pain in the abdomen, which was much distended, 
and sonorous on percussion. There was no sign of respiratory disease, 
except some quickening of the breathing, and a very slight cough, scarcely 
to be noticed. At this moment, however, when scarlet fever was appre- 
hended from the great frequenc}* of the respiration, the drowsiness, and 
the tremulous character of the muscular movements, auscultation and 
percussion revealed the true nature of the sickness in the shape of a lobar 
pneumonia of the lower lobe of the left lung. 

In a majority of the cases, however, instead of the obscure and decep- 
tive onset we have just described, pneumonia begins with fever, accelera- 
tion of the respiration, pain in the side, and short, dry cough. In some 
instances the disease supervenes upon catarrh or bronchitis. The child 
ceases to play, refuses to be amused, and is either irritable and cross, or 
lies listlessly upon the bed, or, if still quite young, insists upon being- 
kept upon the lap. In some few cases, in very young children, convul- 
sions occur. The appetite is lost, or else very much diminished ; the 
thirst is acute, and the disease once established, more urgent than in 
almost any other disease. Yomiting is quite common, especially in young 
children, but diarrhoea is rare, the bowels being generally more torpid 
than usual. From the first day often, and almost always by the second, 
we can perceive either crepitant or subcrepitant rhonchus, and some- 
times bronchial respiration, confined usually to one side, and more fre- 
quent below than above, though, be it remarked, not at all rare over the 
latter part. 

As the case proceeds, the fever increases, the bronchial respiration be- 
comes more distinct and is heard over a larger extent of surface, whilst 
the rales diminish in abundance. The skin is now very hot and cliy, so 
as to impart a burning sensation to the hand ; the pulse augments in fre- 
quency, seldom counting less than 140 in the minute, often mounting to 
160, and in severe cases, and in young children, even to 1*70, and becom- 
ing full and hard; the respiration becomes more and more accelerated, 
until it rises to 40 or 50, and in a great many cases to 60, 10, or even 80, 
while it often becomes at the same time oppressed, and, when full inspi- 
rations are made, painful; the cough is frequent, dry, or almost dry, and 
painful at first, but after a few days begins to be moist, and, in children 
over six or seven 3^ears of age, is not unfrequcntly at tended with an ex- 
pectoration of rusty or sanguinolent sputa; the thirst continues intense, 
the appetite is null, and the child is very restless and irritable, or drowsy 



168 PNEUMONIA. 

and inattentive. About the fourth or fifth day, as a general rule, the dis- 
ease has attained its height, the febrile and local symptoms being then 
most marked, and the extent of the inflammation greatest, as shown by 
the physical signs. 

At this stage of the disease, the bronchial respiration is generally 
strongly marked, being clear and distinct, audible both in inspiration 
and expiration, and accompanied by bronchophon}^ or increased reso- 
nance of the cry. The dulness on percussion is also very evident, the 
change from the natural sound being easily perceptible on a comparison 
of the two sides. 

The symptoms generally remain stationary at this point for one or two 
da}~s, and then begin to subside. The heat of skin diminishes and per- 
spiration often appears ; the pulse falls in frequenc}' and force ; the res- 
piration becomes slower, easier, and full inspirations can be taken without 
pain ; the atee nasi no longer dilate ; the cough becomes quite loose, and 
ceases to be painful ; the thirst is less acute ; the child loses some of its 
irritability and restlessness, and if it have been soporose and dull, be- 
comes more wakeful and observant ; the flushing of the face disappears, 
while the expression is more natural. On auscultation, the bronchial res- 
piration is found to have lost some of its intensity ; it has become more 
distant, or it is heard only in the expiration, and is mingled with, or in 
part replaced b} T , crepitant or abundant subcrepitant rhonchus. The dul- 
ness on percussion is less marked. A little later, the fever ceases entirely, 
the respiration reassumes its natural rate, the appetite returns, the thirst 
disappears, the cough subsides very much, and the child begins to be in- 
terested in its toys or occupations. About the tenth or fifteenth day, and 
in some cases rather earlier, convalescence is fairly established, though 
auscultation may still reveal some prolongation of the expiratory sound 
and diffuse resonance of the voice. 

In unfavorable cases, death seldom occurs early in the disease, but 
usually at some distance of time from the invasion,' - and in consequence, 
no doubt, of the transition of the inflammation into the third or sup- 
purative stage. In such cases the disease has usually pursued the course 
just described up to the period of resolution; but, instead of resolution 
and convalescence taking place, the fever continues, though perhaps with 
diminished violence, the skin being less intensely hot, and the pulse less 
full and active, while it remains quite as frequent. The breathing is 
sometimes less frequent than before, but it is often more laborious, and 
very generally it becomes irregular, and is easily hurried under exertion. 
The cough varies very much, being sometimes almost suppressed, and in 
other cases very troublesome ; it is almost always loose. The strength 
diminishes, the voice becoming weak and feeble, and the muscular move- 
ments tremulous and languid; the face looks pale, haggard, and sunken; 
the child is sometimes very restless, tossing about from time to time on 
the bed or lap, with a quick, short, and evidently feeble movement, or it 
is dull and soporose, awakening only when spoken to, but showing then 
by its fretfulness and peevishness that its intelligence is retained. While, 
these symptoms are present, the extent over which the bronchial respi- 



SYMPTOMS OF THE PARTIAL FORM. 169 

ration is heard has generally augmented, showing the gradual extension 
of the hepatization, while outside of the part where the respiration is 
blowing, and sometimes over the same part, and intermingled with that 
sound, are heard more or less copious subcrepitant and mucous rales. 
This condition seldom lasts more than two or three da}<s, at the end of 
which time the child dies in a state of coma, or after one or more con- 
vulsive seizures, which are the result of a gradually increasing asphyxia. 

In other cases, again, the termination is more gradual. The child, after 
presenting many of the above symptoms, may seem to improve somewhat. 
The fever may diminish, the appetite return to some extent, the respira- 
tion become easier, the restlessness subside, and the child becomes more 
cheerful again ; but the face continues pale, emaciation makes progress, 
the appetite fails again, the pulse remains frequent, diarrhoea comes on, 
the cough becomes more troublesome, thrush often attacks the mouth, 
the strength deca3 T s continuairv, and, after some weeks perhaps of strug- 
gling, the child dies in a state of great emaciation and debility. 

The S3 T mptoms of partial pneumonia are much more obscure and uncer- 
tain than those of the lobar form of the disease. Owing to the fact that 
the inflamed patches of the lung are disseminated or scattered through 
healthy portions of the organ, the signs afforded by physical examination 
are either very imperfect, or entirely masked by the sounds produced in 
the healthy texture. We are forced, therefore, to depend much more in 
this than in the lobar form, on the rational symptoms, in determining the 
nature of the sickness. The rational sjmiptoms of partial pneumonia are 
nearly the same as those of the lobar form. The chief differences be- 
tween the two are in regard to the pain, the dyspnoea, and when there is 
expectoration, in the amount of the sputa. The febrile and nervous 
symptoms, and the disturbances of the digestive system, are the same in 
the two forms, the only difference being in their degree of severity. In 
the lobar variety they are usually more acute and severe than in the 
partial. The local symptoms present important differences which should 
be noted. In the form under consideration, the pain is either wanting 
entirely, or is much less acute than in the lobar form. When the inflamed 
patches are few in number, and they are seated in the central parts of 
the lung, there is entire absence of pain ; but when they are more numer- 
ous and superficial, pain is complained of, but it is usually diffuse, of 
slight intensity, changeable, and felt only during cough, or during full 
inspirations. It makes its appearance commonly on the first day, and 
very seldom after the third. Cough is rarely wanting. It usually marks 
the onset of the sickness, is extremely variable as to its frequency and 
severity, and is not acutely painful, as in the lobar form, unless the in- 
flamed patches be superficial. There is seldom any considerable amount 
of expectoration, and in some cases none; when there is any it is small 
in quantity, and it may or may not be characteristic. In one case, how- 
ever, that came under our observation, in which we had every reason to 
believe, from the nature of the rational symptoms, and from the absence 
of physical signs, that the disease was partial pneumonia, there was a rare 
expectoration of thick, viscous mucus, streaked with blood. The respira- 



170 PNEUMONIA. 

tion is accelerated, and, when the lesion is at all extensive, there is dysp- 
noea, the degree of these symptoms being determined by the extent and 
number of the inflamed patches. 

The physical signs are not, as above stated, very significant. The per- 
cussion is natural, the amount of tissue consolidated being insufficient to 
affect the sonorousness of the chest. Auscultation affords no signs of 
the pneumonic inflammation when the number of affected patches is 
small; when the} 1 " are more numerous it is of some, but not of very great 
utility. Crepitant rale is sometimes heard here and there over circum- 
scribed points of the thorax, and, disseminated in the same way, there is 
also heard in some instances rude respiration, prolonged expiratory mur- 
mur, and bronchial respiration. When, as often happens, this form of 
the disease coexists with bronchitis, it will be entirely concealed by the 
dry and moist rales of the latter affection. 

The duration of pneumonia has been fixed with considerable accuracy 
b}" the observations of various persons. As a general rule, the disease 
reaches its highest point of severity in about four or five da} T s, then re- 
mains stationary for one or two da}'s, and diminishes regularly until 
between the tenth and fifteenth da} T , when convalescence is established. 
In our own practice, the longest duration in 22 unmixed cases, in which 
the period was accurately noted, was It da^^s, and the shortest 5. The 
duration of the 19 cases was as follows: in 1 case, IT days; in 2 cases, 
14 days; in 1, 11; in 4, 10; in 5, 9; in 3, 8 ; in 2, 1 ; in 2, 6; and in 2, 5 
days. One case lasted 33 clays, but it was accompanied and followed 
by bronchitis. 

Particular Symptoms; Physical Signs. — In order to practise aus- 
cultation and percussion in a young child, it should be placed, hj the 
mother, in a sitting posture on her knee, while the physician, kneeling on 
the floor, or sitting on a low chair, makes the examination he deems 
necessaiy. If the child be old enough to take notice, it should be at- 
tracted and amused by some toy or glittering object. Even, however, 
should it cry violently, much valuable information is to be obtained by 
the examination, for we can ascertain the presence or absence of rhon- 
chi and their characters during the deep inspirations between the cries, 
and can observe resonance of the cry and cough, and practise percussion. 

The physical signs of lobar pneumonia are crepitant or subcrepitant 
rhonchus, feeble respiration, bronchial respiration, bronchophony^, reso- 
nance of the cry and cough, and dulness on percussion. They are, in fact, 
the same in the great majority of cases as in adults. Under five years of 
age, this form often begins with subcrepitant rhonchus, while after that 
period the earliest stethoscopic signs are crepitant rhonchus, or feeble 
respiration. The bronchial respiration makes its appearance soon after 
the subcrepitant or crepitant rhonchus, is heard first in the expiration, 
and then in both inspiration and expiration, and is accompanied by 
bronchophony, resonance of the cry and cough, and dulness on percus- 
sion. Bronchial respiration was present in 46 of the 5T cases of lobar 
pneumonia observed by ourselves; crepitant rale was present in 31, and 
subcrepitant in 10. 



RATIONAL SYMPTOMS. 171 

These alterations of the auscultatory phenomena are confined to one 
side, in the great majority of cases, and are best observed over the pos- 
tero-inferior portion of the lung. MM. Rilliet and Barthez state that 
they have never known the bronchial respiration to disappear, in favor- 
able eases, before the fifth day, and in the majority not before the seventh, 
eighth, or ninth; while, in fatal cases, it continued to the moment of death. 
Its persistence is always a highly unfavorable sjTuptom in very young 
children, whilst in those who are older, as in adults, it sometimes remains 
for several days or weeks, though the general symptoms have entirely 
disappeared. 

Rational Symptoms. — Cough ma}^ be said to be invariably present. 
It is dry at first, and not very frequent, but in one or two days becomes 
more frequent, often very troublesome, and from dry and harsh, becomes 
more or less humid and loose. It continues until the disease moderates, 
lasting generally from nine to sixteen da3 T s. In fatal cases it usually per- 
sists to the last. In infants it is not very frequent, occurs in short par- 
oxysms, and in fatal cases often ceases one or two days before death. 
MM. Rilliet and Barthez remark that in pneumonia of the upper lobes, it 
has a peculiar character. It is little, short, smothered, as it were; or 
piercing, teasing, or slightly hoarse. We will merely add that cough is 
sometimes scarcely noticeable in cases which simulate hydrocephalus, 
during the early part of the attack. In a case already referred to, that 
occurred to one of ourselves, in which the s3 T mptoms bore for several 
days very much the aspect of a meningeal attack, there was no full cough 
whatever during the first two daj 7 s ; on the third day, though auscultation 
and percussion showed the existence of pneumonia of the upper lobe of 
the right lung, the child coughed only three or four times, and it was not 
until the sixth day that it became at all frequent. In three other cases 
the cough was so slight in the early stages of the disease, during the 
continuance of the cerebral symptoms, as not to have been noticed un- 
less particularly inquired after. Later in the attack, after three, four, or 
five days, and as the cerebral s} T mptoms moderate, the cough became 
frequent and loose, and the pneumonic symptoms pursued their regular 
course. 

Expectoration is almost invariably absent under five j^ears of age. MM. 
Rilliet and Barthez, and Dr. Gerhard, have never observed rust-colored 
sputa under the age mentioned. In older children there is sometimes, 
though not very often, voluntary expectoration. Even in them, however, 
the sputa seldom present the characteristic rust-color and viscidity ob- 
served in adults, but consist simply of mucus tinged with blood, or of 
whitish, brownish, viscous, or non-viscous phlegni. We once, however, 
saw a child three and a half 3 T ears old, voluntarily expectorate viscid 
mucus, tinged copiously with blood. Sanguinolent expectoration was 
noticed in five of the fifty-seven cases seen by ourselves (not including 
the one just spoken of). In three the sputa were of the characteristic 
rust}' color, in one thejr were composed of mucus streaked with blood. 
and in another portions of mucus streaked with blood were rejected by 
coughing, and some also by vomiting. The age of the live subjects, just 



172 PNEUMONIA. 

alluded to, was in each case between five and nine years. In another 
case (not included amongst the five), in a girl seven years old, affected 
with lobar pneumonia supervening upon pertussis, there was a free expec- 
toration of tenacious mucus, sometimes streaked or dotted with blood, 
sometimes brownish, and sometimes rust-colored. 

M. Yalleix mentions a whitish or sanguinolent viscous froth, as some- 
times escaping from the mouth of new-born children laboring under the 
disease, and Bouchut has also noticed in a single case, a little reddish 
sanguinolent froth, situated on the edge of the lips of an infant with pneu- 
monia. We have never met with this s} T mptom, but know of one case of 
a child within the month, who, during an attack of pneumonia, vomited 
mucus tinged with blood. The child died, and presented the lesions of 
pneumonia. The nipples of the mother were perfectly healthy, so that 
the blood could not have been sucked by the child from them, but must 
have consisted of the sputa which had been swallowed after being coughed 
into the fauces. 

It is scarcely necessary to say that the absence of expectoration is only 
seeming, for children undoubtedly cough the sputa into the fauces, whence, 
instead of being rejected, as by the adult, they pass into the stomach. 

Thoracic Pain. — It is impossible to ascertain the presence of this sj^mp- 
tom with positive certainty prior to the age at which children talk, and 
very often not for some time after, as they refuse or do not know how to 
describe their sensations. And } T et, even in infants, the presence or 
absence of the stitch in breathing, and of pain in coughing, may be in- 
ferred, almost with certaint}', b}^ watching the gestures and expression of 
the child, and the cries which accompairy a full inspiration and the act 
of coughing. In effect, the deep inspirations induced by moving the child, 
those which take place during vomiting and gaping, and those also which 
occur in the act of coughing, cause the child to cry out suddenly and 
sharpty, and give at the same moment an expression of acute suffering 
to the countenance, which can be referred to nothing else than the causes 
just mentioned, and which reveals almost as plainly as words the painfull- 
ness of a deep inhalation and of the act of coughing. In older children, 
we have several times known the pain to be most intense, causing bitter 
and repeated complaints, with crying, fretting, and evident acute suffer- 
ing. The seat of pain, as complained of by children who talk, ought also 
to be noticed, since the account given Iry them might well mislead an 
unwary and inexperienced physician. It is quite common, in fact, for 
them to refer the pain to the false ribs, to one of the flanks, to the abdo- 
men, and even to the hip. 

The respiration is always quickened, except where the constitution of 
the patient has been greatly deteriorated by long and severe illness or 
other causes, under which circumstances it ma} r remain at the normal 
rate, or be very slightly accelerated. This symptom usually dates from 
the invasion, soon after which the breathing rises as high as 40, 50, and 
60 in the minute in older children, and from 60 to 80 in the younger. 
It sometimes becomes excessively rapid, reaching, as it did in a case of 
pleuro-pneumonia in an infant six weeks old under our charge, 128. In 



RATIONAL SYMPTOMS. 173 

favorable cases, the acceleration subsides usually about the seventh, 
eighth, or ninth day. In most of the cases the breathing is eA r en and 
regular, while in others it is short, abdominal, uneven, and jerking. 
When the dyspnoea is very great in a j'oung child, the nostrils dilate 
widely, the mouth remains open, and its angles are drawn downwards 
and outwards ; the last of these sjunptoms is almost a fatal one. Some- 
times the rhythm of the function is changed, so that it begins with a 
sudden, active, and moaning expiration, followed by the inspiration, after 
which comes the interval of rest. MM. Rilliet and Barthez state that 
unequal, jerking respiration, occurs almost exclusively in cases of in- 
flammation of the upper lobes. 

Physiognomy. — The face is almost invariably flushed. The color, at 
first scarlet, becomes after a day or two deeper and darker, and in severe 
cases assumes a livid red tint. We have noticed in very severe pneu- 
monia, in addition to the deep red tint, a peculiar glazed appearance of 
the skin, which looks as though it had been varnished, while the edges 
of the flush are distinct and abrupt. The lips are generally deeply col- 
ored, simultaneous^ with the face. The flush commonly subsides about 
the same time, or a little before the diminution in the rate of the respira- 
tion. In fatal cases, the face is apt to lose its color, and become pale 
and sallow, as the unfavorable symptoms become more and more marked. 
The pallor of the face is most striking in severe and fatal cases occurring 
in infants ; the face is blanched, and the features pinched. 

The expression of the face is one of anxiety and oppression in the 
earl} T stage ; in very severe cases, or those about to terminate unfavor- 
ably, the features become drawn and contracted. 

Fever exists in all the idiopathic cases. The pulse, at all ages, is rarely 
under 130 from the first to the sixth or seventh da}^; in the youngest 
children it rises as high as 140, 160, and even 180 ; while in those who 
are older, it is seldom above 140. In favorable cases, it diminishes about 
the fifth, sixth, or seventh day. In fatal cases, it is apt to diminish at 
the same period, but soon becomes more frequent and continues so to 
the end. 

The skin is hot in the beginning, and continues so until the disease 
subsides. The heat is intense in severe, but not so great in milder cases. 

The nervous system shows more or less marked sj-mptoms of disorder. 
There is restlessness, peevishness, and irritability during the day, and 
these increase towards evening. As the night advances, the child be- 
comes still more restless ; infants will not sleep except in the arms, and 
wake crying or fretting every few minutes or hours ; older children sleep 
uneasily, talk in their sleep, or start and cry out, and are often delirious. 
In some instances, the irritability is most distressing, both to the child and 
to those around. The child is constantly fretting and whining; it wants 
its playthings, but will not touch them; food, but rejects it: and slaps 
and scolds at everything about it. Convulsions sometimes occur at the 
invasion. They last an uncertain length of time, and are usually fol- 
lowed by insensibility, from which the child wakes with fever, accelerated 
respiration and cough, indicating the true seat of disease to be the lungs, 



174 PNEUMONIA. 

and not the brain, as might at first be supposed. We have met with but 
three cases attended with convulsions. One occurred in a boy between 
ten and eleven years of age, on the second day of the disease. The 
attack was induced more, however, by an unwholesome meal taken on 
the first day of his sickness, than b} T the mere effect of the local inflam- 
mation. In a second case, which occurred in a boy between five and six 
years old, there were two convulsive seizures, a violent one on the first 
da} T of the pneumonia, and a slighter one a few days later. In the third 
case, which occurred in a boy aged two } T ears, the pneumonia occurred 
in the course of intermittent fever ; there were three marked convulsions, 
but the child subsequently recovered perfectly. The headache is some- 
times very severe ; in a few instances we have known it to be so violent 
as to constitute the most prominent symptom of the case. On one occa- 
sion, indeed, it was so intense, and so much complained of, during the 
first two days of the fever, as to withdraw our attention from the true seat 
of disease, and it was not until the third day that we discovered the ex- 
istence of pneumonia. The cough was in this, as in other instances, in 
which the nervous symptoms were strongly marked, so slight as to escape 
notice. 

Digestive Organs. — Complete anorexia is generally present from the 
first ; the thirst is intense, greater indeed, than in almost any other affec- 
tion of childhood. The tongue is moist, as a general rule, and covered 
with a whitish or yellowish fur. Vomiting and diarrhoea occur at the in- 
vasion of about half the cases in hospitals ; in private practice, vomiting 
often occurs, but diarrhoea much less frequently. 

Urine. — The amount of urine is mat erially lessened in acute pneumonia, 
the extent of the reduction being from one-third to one-half (Parkes). 

During the height of the disease the urea is increased, and with it, as 
in most febrile diseases, the uric acid. Simon and Redtenbacher first 
called attention to the fact that the chloride of sodium is diminished or 
entirely absent during the early period and at the commencement of 
hepatization, and reappears during, or rather after resolution ; and further 
researches have fully confirmed this observation, since very few excep- 
tional cases have yet been recorded. The disappearance does not depend 
upon the reduced diet, since Howitz and Parkes both state that even when 
chloride of sodium is administered, none can be detected subsequently 
in the urine. And the fact that it is in reality retained in the s} T stem, is 
further shown by the very excessive excretion during convalescence. 
According to Beale's observations, the exudation in the lung is very rich 
in chloride of sodium ; and it has been found that as this salt disappears 
from the urine, it appears in the sputa, and in turn as it returns in the 
urine, it disappears from the sputa. 

It is true that more extended observation has shown that the chloride 
of sodium is absent or deficient in many other affections, both febrile and 
inflammatory ; but still, although not pathognomonic of pneumonia, this 
sign is an aid in its diagnosis, and probably serves to distinguish it from 
collapse of the lung or tuberculous consolidation. 

One more condition of the urine in pneumonia, although as yet, so far 



DIAGNOSIS. 175 

as we know, only noticed in adults, deserves attention. We allude to the 
presence of albumen, which has been noticed by several observers, as 
Finger. Becquerel, Parkes, and Heller, in almost 45 per cent, of their 
cases ; though others have but rarely found it. 

The period of its occurrence is variable; according to Heller and 
Parkes, it appears at the time when the chlorides are most deficient, as 
hepatization advances. The fatality is much increased in cases where 
albuminuria is present ; the combined record of the observers above re- 
ferred to, yielding a mortality of almost 50 per cent, of such cases ; whilst 
the mortality in cases without albuminous urine was only 14 per cent. 
According to Parkes, renal cj'linders are very common in the albuminous 
urine of pneumonia ; and a little blood is also frequently present, but is 
usually out of all proportion to the albumen. 

Diagnosis. — The lobar pneumonia of children is most liable to be 
confounded with bronchitis, pleurisy, and meningitis. There is little 
probability, however, that lobar pneumonia would be mistaken for bron- 
chitis by any but a careless or incompetent observer ; for the presence, 
in the former, of snbcrepitant, and very often of crepitant rhonchus, of 
bronchial respiration, bronchophony, resonance of the cry and cough, and 
dull or flat percussion, confined to one side, would easily distinguish it 
from bronchitis, which is marked by dry and moist rales over both sides 
of the chest, and by a normal condition of the percussion. It is difficult 
and often impossible, as already stated, to detect the existence of partial 
pneumonia, at least to make the diagnosis with absolute certainty. The 
cause of the difficulty, as before explained, lies in the fact that it presents, 
in a great many instances, no clear physical signs. When the number of 
inflamed nodules scattered through the healthy texture of the lung is 
small, and especially when they are deeply seated, no alteration whatever 
of the natural respiratory sounds can be perceived, and we are obliged to 
depend entirety upon the rational symptoms, — the accelerated breathing, 
oppression, pain, cough, fever, and the absence of the physical signs of 
other pulmonary inflammation. Sometimes the presence of the charac- 
teristic sputa of pneumonia will, in older children, make the diagnosis 
clear. When the inflamed nodules are situated near the surfaces of the 
lung, we may, in some instances, detect crepitant or fine subcrepitant 
rale, and bronchial respiration, over circumscribed portions of the lung, 
and there would be, under such circumstances, no hesitation as to the 
diagnosis. 

It has been stated that pneumonia might be confounded with pleurisy. 
This could not happen in regard to the partial form, as the slighter de- 
gree of the pain, the limited extent of the rale and bronchial respiration, 
and the absence of dulness on percussion in the latter, would prevent such 
a mistake. The distinction between pleurisy and the lobar form is more 
difficult, but may generally be made out by attention to the fact that 
pleurisy is rare under six years of age ; by the greater severity of the pain, 
the absence of rhonchi, the effect of change of position on the sounds 
yielded by percussion, the shorter duration and great or mildness of the 
general symptoms, the entire absence or small amount of expectoration, 



176 PNEUMONIA. 

and by the continued dryness of the cough in pleurisy ; and, lastly, by 
the disposition on the part of pleurisy to become chronic, while pneumonia 
nearly always runs an acute course. 

Pneumonia in children not unfrequently simulates, in its early stage, 
an attack of meningitis, constituting a form of the disease sometimes 
called cerebral pneumonia. Vomiting, constipation, extreme irritabilit}^ 
or restlessness, and complaints of headache, occur in both ; while the ab- 
sence of thoracic symptoms to draw attention to the true seat of the 
disease in pneumonia, may readily mislead. The cough in the early stage 
of pneumonia is sometimes very slight, and not being observed by the 
attendants, is not reported to the physician. The freqnencj^ of the respi- 
ration is overlooked, or, if noticed, is ascribed to the fever, which is sup- 
posed to depend on the cerebral inflammation. In pneumonia, however, 
the vomiting is not usually very frequent, nor very obstinate, nor are the 
bowels so much constipated as in acute hydrocephalus. These variations 
from the ordinary symptoms of acute hydrocephalus, minute though they 
be, ought to attract the notice of the physician, and lead him to examine 
the case more carefully; when, in all probability, the physical signs would 
immediately reveal the pneumonia. We may mention, in illustration, that 
we attended a boy six years old, who, for three da3 T s, suffered from violent 
fever and excruciating headache, which last was the only symptom com- 
plained of. There was neither cough, expectoration, nor any marked ac- 
celeration of the respiration. After three days the headache moderated, 
and he had slight pain in his side ; on examination, we found him labor- 
ing under well-marked lobar pneumonia. In April, 1847, one of us was 
called to see a boy nineteen months old, who had been taken sick with 
slight fever, a little hoarse cough, and mild pharyngitis. After remain- 
ing in this condition for five daj's, he began to be drows}^ and very irri- 
table, the surface became pale, and the extremities rather cooler than 
natural. From the sixth to the tenth day, there was great somnolence, 
the child sleeping nearly all the time ; when waked from sleep, he was 
always exceedingly irritable and cross, scarcely opening his eyes, and 
then shutting them again immediately to avoid the light, which was evi- 
dently painful. During this time he took scarcely any food, but little 
drink, and vomited several times freely ; the bowels were moved without 
medicine; the surface remained very pale, and the extremities often cool; 
the pulse was frequent and small, the respiration perfectly regular, for 
which reason it attracted no attention, and there was no cough whatever. 
Under these circumstances, we hesitated between regarding the case as 
one of meningitis, or of hydrocephaloid disease, as described by Dr. M. 
Hall. We took the latter view, however, and treated it with small quan- 
tities of brandy, cold to the head, and the frequent employment of mus- 
tard pediluvia. From the eleventh clay the child began to improve ; it 
would open its eyes from time to time, and look round for a few moments ; 
the face began to show a slight degree of color, and the palms of the hands, 
which had been white and transparent, exhibited a tinge of the natural 
pink hue which they have in children. Observing about this time that 
the respiration was accelerated, though perfectly free and regular, and 



PROGNOSIS. 177 

without cough, we counted it, and were astonished to find it 80 in the min- 
ute. We now examined the chest carefully, and finding slight dulness 
on percussion with bronchial respiration, over the inferior half of the left 
side behind, immediately understood the nature of the case : it was one 
of latent pneumonia, simulating hydrocephalus. The child was now 
treated for pneumonia, and after an illness of twenty-seven days longer, 
recovered perfectly. As the case progressed, the rational signs of pneu- 
monia were more and more apparent, the cough becoming frequent and 
painful, and after a time loose, while the cerebral symptoms gradually 
disappeared. 

In addition to these cases, we have met with several others which during 
the early stage resembled very closely the invasion of cerebral disease. 
One of these has already been referred to in the account of the symptoms 
of the disease. Two others occurred in children within the year, and one 
in a child between one and two years old. Attention, however, to the 
rate of the respiration and the physical signs, and the presence of slight 
cough, revealed, in two of them, after a little hesitation, the true charac- 
ter of the attacks. The third case, which occurred in one of the children 
within the year, was unattended by an}^ cough during the first few days, 
and was, therefore, very obscure, until our attention was attracted by an 
acceleration of the respiration, when the physical signs, and at a later 
period, cough, explained the real nature of the attack. We may remark, 
in addition, that in all these cases, the absence of constipation, the infre- 
quency and short duration of the vomiting, and some clearness of the 
intelligence when the child was fairly roused, though but for a few mo- 
ments, from its state of somnolence, were other motives for doubting the 
attacks to be meningitis. 

Dr. West states that pneumonia is often overlooked in teething chil- 
dren, in whom the cough is called a tooth-cough, whilst the diarrhoea, 
which frequently occurs, and becomes the prominent symptom, is sup- 
posed to depend upon dentition, and is alone attended to. The diarrhoea 
is obstinate, and when, at last, the cough attracts attention, it is ascribed 
to phthisis, and the physician is astonished to find at the autopsy puru- 
lent infiltration of the lungs, but no tubercles, and no disease of the 
intestines. The diagnosis is to be correctly made, under such circum- 
stances, only by careful physical examination. 

Prognosis. — It may be stated in general terms, that pneumonia is the 
more dangerous in proportion as the child in whom it occurs is younger ; 
and that the secondaiy, consecutive, or intercurrent form of thei disease 
is much more dangerous than the primary. It is usually supposed to be 
almost necessarily fatal in new-born children, and to be very dangerous. 
though less so than in neonati, up to the sixth year of age. There has 
been so much confusion, however, in regard to atelectasis of the lung 
and true pneumonia until within a few years past, that it is scarcely 
possible to trust to former statistics upon this point. From six years of 
age up to fifteen, the disease is generally curable when of the primary 
form; when of the secondary form the result is much more doubtful, 

12 



178 PNEUMONIA. 

and will depend in great measure, of course, on the nature of the disorder 
during or after which it occurs. 

MM. Rilliet and Barthez (loc. cit,, p. 585) state that they lost about 
one-eighth of their cases in private practice. Of these, the youngest was 
a year old, the oldest, three years old. To quote their own words : 
" Some evidently died of accidents caused by the medication (poisoning 
by tartar emetic) ; one was the victim of a relapse, due to fault}?- hygienic 
care ; and others died of cerebral pneumonia of the upper lobe ; they 
were undergoing the process of dentition." In the hospital, they lost a 
seventh of their patients. The subjects under five 3 r ears of age died of 
cerebral, gangrenous, or intestinal complications. Those over five } T ears 
of age died, some because they were scrofulous or feeble, the inflamma- 
tion, though lobar, being double ; and the others, in consequence of the 
inflammation having become complicated with pleurisy, scarlet fever, or 
meningitis. Thej r add, that in the hospital, six-sevenths of the patients 
attacked with secondary pneumonia died. 

In 1862, however, Barthez stated, in a memoir to the French Acadenry 
(3Ied. Times and Gaz., May 10th, 1862), that during the previous *l years, 
having abandoned the use of depletion in the pneumonia of children, he 
had treated 212 cases, with the loss of but 2 patients. 

The results of our own experience, which, it ought to be remarked, has 
been acquired chiefly in private practice amongst the easy classes of 
society, have been as follows : Of 65 cases of well-marked lobar pneu- 
monia, only 2 were fatal. Of these two, one occurred in an infant six 
weeks old, and was accompanied with extensive and violent pleurisy, 
and the other occurred in a child between two and three } r ears old, lasted 
thirt} T -three days, and was attended with considerable bronchitic inflam- 
mation. 

In addition to these, we have seen a certain number of cases which 
are not included in the statistics of our own experience, since some of 
them were only seen, and, perhaps, but a single time, in consultation, 
while a few others occurred among the children in the large public insti- 
tutions of this city. A far larger proportion of these cases proved fatal. 

We m&y conclude, therefore, that pneumonia under two years of age 
is alwa} T s dangerous, and much more so when secondary than when pri- 
mary ; that primary pneumonia, between the ages of two and five 3-ears, 
will terminate favorably in the great majority of cases in private prac- 
tice ; and that when -the disease attacks children between six and fifteen 
years of age, the termination is nearly always in health. 

The following are some of the most unfavorable symptoms of the dis- 
ease : convulsions ; small, weak pulse ; extreme rapidity of the respira- 
tion ; persistence of the bronchial respiration in young children ; incom- 
plete resolution of the disease within the ordinary period ; excessive and 
obstinate diarrhoea ; severe cerebral symptoms ; great emaciation ; greatly 
altered physiognomy ; excessive irritability ; and a yellowish tint of the 
skin. M. Trousseau regards as an unfavorable symptom the occurrence 
of swelling of the veins of the hands, which he supposes to depend on an 
obstacle to the function of hsematosis. 



TREATMENT — BLOODLETTING. 179 

Treatment. — "When the last edition of this work was published, eleven 
years ago, a great change had begun to take place in medical opinion as 
to the proper treatment of disease, and especially of acute disease. In 
that edition this change of opinion was referred to, and its effect upon 
our own convictions and methods of procedure freely acknowledged. 
Since that period this revolution, as it might be called, has continued to 
make progress, until, at the present moment, no one can candidly express 
his own views without referring to it. In view of these facts, we shall 
not hesitate to write at some length on the treatment of pneumonia, in 
order that our readers, and especially the 3 r ounger members of the pro- 
fessionally be able to comprehend not only the changes that have taken 
place, but some of their causes. 

There is another consideration which has been forced upon us by time 
and experience, which makes us unwilling to dismiss the treatment of so 
important a disease in a few words, and this is, that the method of cure to 
be followed in individual cases must be determined not alone by the 
simple fact that the patient has an inflammatory exudation in the lung- 
tissue, but, in large measure, try the state of the general vitality of the 
subject. What folly, for instance, to suppose that we can safely apply 
the same therapeutic measures to a case of pneumonia in a child just 
issuing out of severe measles, to one in the midst of a dangerous tj^phoid 
fever, to a third in the spasms of hooping-cough, or to a fourth who was 
yesterda}' in consummate health, with every function, up to the moment 
of the attack, in the finest possible working order. To be sure, this is 
putting the case in very strong terms, but they are not too decided to 
make our meaning clear. 

Moreover, we think there is a tendency, in some of the later works on 
diseases of children, and in some, too, of the general treatises on the 
practice of medicine, to lengthened scientific descriptions of anatomical 
changes, symptoms, diagnosis, &c, and to a corresponding diminution 
of the space devoted to therapeutics. This error, as we think it (not to 
be wondered at, perhaps, when we consider the relative dirncuhy of writ- 
ing on these different subjects), we desire to avoid, and, indeed, we have 
found it impossible to state our opinions on the subject except at some 
length. 

Bloodletting. — Twenty years ago depletion formed an almost inevitable 
item in the treatment of pneumonia, but, within the last eight or ten 
years, the views of most observers have undergone a more or less radical 
change in regard to its utility and necessity. Some have abandoned it 
altogether ; others employ it still to a moderate extent. In order that 
the 3 7 ounger practitioner may see the changes which have taken place in 
this respect, we shall quote the views of some of the more important 
authorities, and then give our own. 

Dr. Charles West (4th Am. ed., from 5th English ed., page 285) "can- 
not forget the good results which I saw years ago from the abstraction of 
blood at the outset of an attack of pneumonia in previously healthy chil- 
dren." He, however, does not advise depletion when small crepitation 
has become generally diffused, still less when dulness or bronchial breath- 



180 PNEUMONIA. 

ing is perceptible. He gives no statistics as to his own results whatever. 
Dr. J. Lewis Smith, of Xew York, in his work, does not even mention 
bloodletting. Dr. Thomas Hillier, of London, says of bloodletting that 
it "is now for the most part discarded. I have never had occasion to re- 
sort to it." He says further, however, that cases might occur where it 
would be proper to recommend it. Such conditions would be, the second 
da} r of the disease, a large extent of inflammation of the lung-tissue, full 
and bounding pulse, great pain and dyspnoea, and a temperature of 105° 
or more. If these conditions existed in a previously healthy child, he 
would think it wise to take a few ounces of blood from the arm. We have 
already referred to the communication from M. Barthez to the Academy 
of .Medicine of Paris, in April, 1862, intended to vindicate the expectant 
treatment of pneumonia in early life. In this paper it is stated that of 212 
cases of lobar pneumonia, occurring between the ages of two and fifteen, 
in the course of seven years, at the Hopital Ste. Eugenie, only 2 had a 
fatal termination, although no approach to active treatment was adopted 
in more than a sixth of the number. Dr. J. Hughes Bennett gives, in 
The Practitioner, for May, 1869, the results of the restorative treatment of 
pneumonia in 153 cases. Of these, 129 were simple and 24 complicated 
cases. Of the 129 simple or uncomplicated cases, of which 35 were 
double, all recovered. Among the 24 complicated cases there were 5 
deaths, making of the whole number a mortality of 1 in 30? cases. Dr. 
Bennett's cases all occurred in adults, but the results are useful to us as 
showing the effects of this kind of treatment. 

In the last edition of this work it was stated that one of us had treated 
50 cases of well-marked lobar pneumonia, with 2 deaths, in private prac- 
tice. Full notes of only 40 of these cases were kept. Of the 46 cases, 
39 were primary or uncomplicated, and 7 secondary or complicated. The 
2 fatal cases occurred, one at six weeks old, and this was attended with 
very severe pleuritic inflammation, and the other between two and three 
} T ears old ; the latter case lasted 33 daj's, and was attended with consid- 
erable bronchitic inflammation. Depletion was einpk^ed in 16 of the 39 
primary, and in 2 of the 7 secondary cases. It is proper to state that 
depletion was not emplo3 T ed in either of the fatal cases. 

How difficult is the task of estimating the comparative value of differ- 
ent plans of treatment in any given disease. MM. Killiet and Barthez lost 
one-eighth of their cases of pneumonia in private practice, and one-seventh 
in hospital. We lost one-twenty- fifth of ours in private practice ; a re- 
sult very nearly as good as Dr. Bennett's, though ours were all in chil- 
dren under 15 3-ears of age, and of 37, whose ages were recorded, 19 
were under 5 years (2 in the first year, 3 in the second, 5 in the third, 
4 in the fourth, 5 in the fifth). Dr. Bennett condemns bleeding almost 
wholly; we took blood in 16 of 39 primary, and in 2 of 7 complicated 
cases, and did not deplete at all in the 2 fatal cases. M. Barthez re- 
ports 212 cases, treated by the expectant method, with only 2 deaths, or 
less than one in a hundred; and these cases, too, in children between 2 
and 15 years of age, in hospital practice. These last statistics are the 
most surprising we have seen. We have been unable to find the original 



TREATMENT — BLOODLETTING. 181 

memoir of M. Barthez, but have seen the report made to the Academy of 
Medicine, by M. Blache (Bulletin de VAcad. Imp. de Medecine, t. xxx, 
p. 21). on the memoir, in which it is stated that "the author has taken 
care to eliminate the lobular or generalized pneumonias, the pseudo-lobar 
pneumonias, broncho-pneumonias, and catarrhal pneumonias ; he has also 
thrown aside the lobar congestions which occur in the course of low fevers, 
and the secondary lobar hepatizations ; that is to say, those which occur in 
the course of any well-determined disease, and particularly tuberculosis." 
We cannot help thinking that the elimination of so many forms of pneu- 
monia, must be a chief reason for the very great success of the plan of 
treatment used. 

This much, however, has been plainly established by the observations 
and experience of late years, that the old plan of bleeding, as a rule of 
absolute practice, merely because of the existence of pneumonia, and 
especially the Sangrado system of bleeding, coup sur coup, was a gross 
mistake, and one which did great harm. Bat we do not think it has been 
proved that the restorative or expectant system, to the exclusion of blood- 
letting under any circumstances, is alwa} T s and inevitably the right one. 
We have been led to think that bloodletting was not the only cause of 
the heavy mortality under the old sj^stems of treatment, but that the use of 
such agents as antimony, ipecacuanha, and perhaps calomel, in large and 
frequently administered, and long-continued doses (and particularly the 
antimon}'), by their action upon the stomach, in destroying all power to 
take and digest food, and b} T the general prostration which their action 
(especially antimon}') upon the nervous system occasioned, were answer- 
able for a large share of the fatal results of those days. We doubt, in 
fact, whether depletion, used in airvthing like moderation, is not safer 
for the patient than the continued use, for two or three days, of nause- 
ants and depressants, more particular^ of antimony. But of the action 
of antimonj" upon children, we shall speak more at length hereafter. 

Our own opinion, after eleven years of additional experience, since the 
publication of our last edition, is, that depletion should not be used save 
in exceptional cases. When the pneumonia is pursuing a regular and safe 
course, it is best to trust to the simple means to be spoken of hereafter — 
to follow a mild expectant method. Where the physician doubts as to 
its propriety, and especially when he is j^oung and inexperienced, it is 
safest to abstain from it entirely, or to employ it only in a very moderate 
degree. But there is a certain class of cases, in which we believe that 
local depletion, by cups and leeches, is not only allowable but most use- 
ful. When the subject is vigorous and strong, with a fine sanguifica- 
tion; when the temperature is very high; the pulse strong and full : the 
muscular force good, and the side-pain and cough very severe, we think 
that the local abstraction of from two to four ounces of blood, at the age 
of three or four years, has great power to relieve all these symptoms. 
Again, when the dyspnoea is veiy great; when the heart pulsates with 
great force, whilst the pulse is small and feeble, showing that the right 
heart is overloaded, and the arteries comparatively empty, in consequence 
of obstruction to the passage of blood through the lungs ; and when the 



182 PNEUMONIA. 

child is tolerably vigorous, and not reduced by previous illness, a moderate 
venesection is often of more use, and of more efficacy in palliating these 
conditions, than any treatment we know of. The quantity to be taken 
should seldom be over four ounces, at the ages of from three } T ears and up- 
wards. We venture upon these statements the more boldly when we find 
such men as Chambers and Niemeyer, and even Bennett, giving the same 
advice. Dr. Bennett (loc. cit.) lays down ainongst his axioms the following : 
" Small bloodlettings, of from six to eight ounces, may be used in extreme 
cases, more especially in double pneumonia and broncho-pneumonia, as 
a palliative to relieve tension of the bloodvessels and congestion of the 
right heart and lungs." Mender ( Text-Booh of Tract. Med., Amer. ed., 
vol. i, p. 184) sa3 T s, pithily: "Highly as I prize venesection, however, in 
certain emergencies which may arise in the disease, I had rather that any 
one, dear to me, and sick of pneumonia, were in the hands of a homoeopath, 
than in the hands of a physician who thinks that he carries the issue of 
the malady upon the point of his lancet." He recommends venesection 
in three conditions: 1. When the pneumonia has attacked a vigorous and 
hitherto healthy subject, is of recent occurrence, the temperature being 
higher than 105° F., and the frequence of the pulse rating at more than 120 
beats a minute. " Here danger threatens from the violence of the fever, 
and free venesection will reduce the temperature, and lessen the frequence 
of the pulse. In those who are already debilitated and anaemic, bleeding- 
increases the danger of exhaustion. Should the fever be moderate, blood- 
letting is not indicated, even in healthy and vigorous individuals." 2. 
"When collateral oedema, in the portions of the lung unaffected b} T pneu- 
monia, is causing danger to life, the pressure of the blood is reduced by 
bleeding, and b} T prevention of further transudation of serum into the 
vesicles, insufficience of the lung, and carbonic acid poisoning are averted. 
Whenever the great frequence of respiration, in the commencement of 
pneumonia, cannot be traced to fever, pain, and to the extent of the pneu- 
monic process alone, as soon as a serous, foamy expectoration appears, 
together with a respiration of forty or fifty breaths a minute, and when 
the rattle in the chest does not cease for a while after the patient has 
coughed, we ought at once to practise a copious venesection, in order to 
reduce the mass of blood, and to moderate the collateral pressure. The 
third indication for bleeding arises upon the appearance of symptoms of 
pressure upon the brain, not headache and delirium, but a state of stupor 
or transient paralysis." We have made this long quotation because the 
authority is so high, and because we have nowhere found such clear and 
concise statements upon this most important point of practice. 

Antimony. — In the last edition of this work it was stated that tartar 
emetic, in the dose recommended by some of the highest authorities of 
the da}', had been found by us a very dangerous drug. Time has but 
confirmed this opinion. At that time we were in the habit of adminis- 
tering it in doses of a forty -fifth or sixtieth of a grain every hour or two 
hours. This was at a time when Rilliet and Barthez used it in doses of 
from two to four grains, dissolved in four ounces of water, in twent3'-four 
hours, for very }'oung children, and for those who were older six grains 



TREATMENT — ANTIMONY — CALOMEL. 183 

in the same space of time. The}' continued it for two, three, or fonr da} T s, 
and advised its suspension should it give rise to excessive vomiting or 
severe diarrhoea. Dr. TTest at that time gave it in doses of one-eighth of 
a grain, at the age of two years, every ten minutes, until vomiting was 
produced ; to be continued every hour or two afterwards for a period of 
twenty-four or thirty-six hours. Dr. West had reduced the doses, and 
the time of continuing it, one-half, between the time referred to and the 
date of his essay on pneumonia, published in 1843. 

The doses used by us, as mentioned above, may seem to some who 
have not employed them ludicrously small, but we soon found that even 
they were quite frequently, in certain constitutions, more than could be 
given with safety. Antimony, even in those small quantities, sometimes 
caused a very peculiar general prostration. Perhaps without any vomit- 
ing whatever, or with ou\y a rare effort at that act, the patient would re- 
fuse all nourishment, become very pale and w r eak, grow limp and motion- 
less, take on a haggard and pinched expression of face, pass into a state 
in which it would pa}~ no attention to what was going on around, be very 
peevish and irritable when disturbed, get a very frequent and feeble pulse, 
and look to an experienced eye as though a very little deeper degree of 
such prostration might end fatany. After seeing this condition a few 
times, and finding that the withdrawal of the drug and the use of small 
doses of brandy (ten to twenty drops in water or milk) every hour or 
two hours, was followed by rapid improvement, we learned the greatest 
caution in the use of the remedy. Of late 3 r ears we never use tartar 
emetic at all, but give, not unfrequentfy, in strong and vigorous children, 
with high febrile heat and rapid circulation, small doses of the precipi- 
tated sulphuret of antimony, alwa} T s watching its effects carefully, and 
withdrawing it at once should the above symptoms make their appear- 
ance. The formula found most useful and safest is the following : 

R. — Antimon. Sulphurat, ..... gr. j. 

Pulv. Doveri, '. gr. iij. 

Sacch. Alb., gr. xij. 

M. et div. in chart, no. xh. One to be given every two, three, or four hours. 

To infants under two years of age it is best to give no antimonj^ at all. 

Calomel. — In former years, in obedience to the prevailing rules of the 
day, we gave calomel in very moderate quantities in some cases of pneu- 
monia. We never felt sure that it was of any special service, and of 
latter j^ears have abandoned it altogether. It is one of the drugs which, 
we think, ought not to be given except under some very clear indication. 
Such indications rarely exist in pneumonia, and therefore we do not pre- 
scribe it. 

Salines. — Citrate of potash, either in the form of the neutral mixture 
or dissolved simply in water with a little sugar, is one of the best febri- 
fuges that can be used. In doses of two and a half grains to children 
over three or four }^ears old, and half a grain to a grain for younger chil- 
dren and infants every two hours, it is an excellent remedy. It may be 
given alone, or combined with small doses of syrup of ipecacuanha and 



184 PNEUMONIA. 

opium. Spirit of nitrous ether may be added when the urine is scanty, 
or when the ipecacuanha cannot be borne. 

The solution of acetate of ammonia, either alone or combined with the 
spirit of nitrous ether, is useful when the child is feeble, and when the 
stomach or bowels are irritable, in which case the citrate of potash some- 
times offends the stomach and acts upon the bowels. The dose of this 
remedy ma}- be from twenty or thirty drops to half a drachm or a drachm, 
according to the age, in sweetened water, or some aromatic water, every 
two hours. 

Ipecacuanha ; Purgatives. — Ipecacuanha is preferable to an timony in 
all conditions except those referred to above. In infants under two years 
of age. in children of highly nervous temperament, or of feeble and deli- 
cate constitutions, in most cases of the secondary form, and in all mild 
cases, it is much safer than the other drug. The most convenient prep- 
aration is the syrup, of which ten drops may be given every two hours at 
four years of age, five drops between one and three years, and from one to 
three drops to infants of two or three months. It is often useful to com- 
bine the spirit of nitrous ether with it, and, when the stomach is irritable, 
or the patient very restless and irritable, with small doses of opium. 
"When the patient is much oppressed by the presence of secretions in the 
bronchia, and not too much prostrated, an emetic is often very useful. 
Ipecacuanha is the most suitable remedy for this purpose, as it produces 
less exhaustion and depression than any other, except, perhaps, alum. 

A purgative dose is useful at the beginning of the attack when the 
child is constipated, and when the abdomen is tumid and hard. A tea- 
spoonful of castor oil, or two teaspoonfuls of simple syrup of rhubarb, 
will answer every purpose. After this "period cathartics need be used 
only so as to keep the bowels moderately soluble. If they are moved 
spontaneously every two or three days, there is no occasion to give pur- 
gative doses. If the}- do not move, a simple enema, or the doses men- 
tioned, will be sufficient. Violent or frequently-repeated doses of purga- 
tives are injurious, by exhausting the patient through the disturbance of 
the stomach which they occasion, or by setting up diarrhoea. 

External Applications. — MM. Rilliet and Barthez were of opinion that 
neither blisters, Burgundy pitch, or tartar emetic plasters, exerted the 
least influence upon any one of the symptoms of pneumonia, but that, 
on the contrary, they increased the fever. Dr. West gave up the use of 
blisters entirely, in consequence of the irritation and fever they occa- 
sioned, and because of the disposition to sloughing which he observed 
to follow their use amongst the poor. At one time we thought we had 
observed great benefit from the use of a blister when other means had 
failed to produce some moderation of the symptoms after four or five 
days. If the}- are used at all, it ought to be with great care, espe- 
cially in very young or feeble children, whose nutrition is depraved. In 
children of less than two or three years old, a blister should never re- 
main on the skin longer than two hours. As a general rule, the mother 
should be told positively to remove it at the end of one hour and a half, 
even thouo-h the surface be still unchanged. A warm bread-and-milk 



TREATMENT — LOCAL APPLICATIONS. 185 

poultice is then to be used as a dressing, and this rarely fails to cause 
vesication in a few hours. Employed in this way, we have had but once 
the misfortune to see a blistered surface slough, and this occurred in a 
child whose skin had been very much irritated by frictions with amber 
oil and ammonia. 

Since the spring of 1845, however, when we were led to make frequent 
use of mustard poultices and foot-baths in the treatment of the bronchitis 
and pneumonia of measles, we have rarely empkyed blisters, but have 
preferred the employment several times a day of the remedies just indi- 
cated. Two parts of Indian meal and oue of mustard, for young chil- 
dren, and for those who are older equal parts of each, are to be mixed 
with warm water, and spread thickly like a poultide on a piece of flannel 
or rag five or six inches square. This is to be covered with fine muslin, 
linen, or gauze, and applied first over the back and then the front of the 
thorax. It ma}' remain from fifteen to forty minutes, or until the child 
cries or complains, or until the skin is reddened. The mustard foot- 
baths ma} T be emploj'ed at the same time with the poultices. These 
applications are useful whenever the oppression is very great, and, when 
resorted to in the evening, the}" often allay irritability, and dispose the 
child to sleep. The number of applications to be made in a day must 
depend on the urgency of the s} T mptoms. We have employed them from 
once a day to eveiy two or three hours. 

Dr. Chambers {Joe. cit.) strongly recommends the use of linseed meal 
poultices, as a " direct restorative means, about the use of which also 
anywhere you need have no manner of hesitation." He claims that it 
allaj's the pain ; relieves dj'spnoea ; induces moisture and activity of the 
skin ; and promotes the absorption of the exudation. He directs the 
poultice to be spread half an inch thick on a cloth or flannel as broad as 
the circumference of the thorax, and deep enough to cover the wdiole 
chest, from the collar bones to the hypochondria. In adults this will 
usually keep in place of its own accord, but in children 3^011 should have 
a tape stitched on in front, and a tape behind, which you can tie over 
the shoulder in the manner of a shoulder-strap. 

Tonics and stimulants are to be resorted to in cases which manifest 
undoubted signs of debility. When, therefore, the attack occurs in a 
feeble child ; in secondary cases ; when the inflammation remains unre- 
solved after the use of other remedies, and when extensive bronchial respi- 
ration persists, though the fever has moderated ; or when, in any case, 
during the acute stage, the child falls into a typhoid state, as shown by 
pallor of the surface, frequent, uneven pulse, dry tongue, prostration of 
muscular power, and either incessant jactitation or the listless quiet 
of exhaustion ; attention must be paid to the state of the constitution 
even more than to the local disease. The vital forces must be sustained 
and strengthened in order to give time and power to carry on the 
operation necessary for the removal of the local obstruction. To effect 
this purpose, we must depend upon the use of food, alcoholic stimuli, 
and certain tonics. The food most suitable for such a condition is milk, 
animal broths, soft-boiled eggs, and perhaps small quantities of raw or 



186 PNEUMONIA. 

slightly cooked meat. The best stimulants are brandy, given either in 
the milk or in water, as the child will best take it, and wine and water, 
or wine-whey. The amount of brandy given may be stated as 3, 4, or 5 
teaspoonsfuls in the course of 24 hours at 4 years of age. The best tonic 
to give in conjunction with the alcoholic stimulus is quinia, which should 
be administered in the quantity of from gr. iv to gr. yj in 24 hours, given 
in divided doses. When the exhaustion is marked, especially when asso- 
ciated with great embarrassment of respiration, and copious viscid secre- 
tion from the bronchial tubes, we should recommend the use of muriate 
of ammonia in doses of gr. iij eveiy 3 or 4 hours, at 4 or 5 years of age, 
given in mucilage or in mist, glycyrrhiz. comp. 

Opium is constantly of great service in the treatment of pneumonia. 
It should alwaj^s be used when the patient suffers much, either from the 
side-pain or from cough, whether this be harassing and exhausting from 
its mere frequency and persistence, or from its effect in developing the 
stitch ; when there is painful jactitation, an unusual degree of distress 
and malaise, or marked tendency to morbid vigilance. When the fever 
is very high, the pulse vibrating, the nerves on a rack, opium is of the 
greatest advantage. The mere comfort it gives is a good warrant for its 
use, but it has long seemed to us to aid in shortening the duration, and 
lessening the severity of the constitutional disturbance. 

The choice of the preparation, and the doses and times of administra- 
tion, must vary in different cases. When used earty in the case, to act 
upon the circulation and alla}^ general irritability, it is best to give it with 
the febrifuge every two or three hours. When used to control cough, it 
can be added to the sulphurated antimony in the form of Dover's powder, 
as already suggested, or to the syrup of ipecacuanha and spirit of nitrous 
ether, in a liquid form ; or, when the cough is particularly troublesome at 
night, as often happens, it can be given with more advantage in a single 
dose, or two doses in the evening. The preparations we have found most 
useful are, laudanum, especially the tr. opii deodorata, paregoric, solution 
of morphia, or Dover's powder. Under six months of age, half a drop of 
laudanum, from five to ten drops of paregoric, or two or three drops of 
the solution of morphia, may be given, and repeated twice or three times 
in the twenty-four hours, according to the effects. From the age of six 
months to the end of the second year, these closes may be doubled. In 
the third and fourth years, two drops of laudanum, ten to twenty of pare- 
goric, five to ten of solution of morphia, may be used several times a da}^. 
Where the remed}' is given eveiy two or three hours, we have found one 
drop of laudanum quite enough at the ages last mentioned. When the 
dose is given only at night, from three to five drops of laudanum, ten to 
fifteen of solution of morphia, and thirty to fifty of paregoric, are sufficient 
as a general rule. After the age of four and five years, the doses must be 
increased in proportion to the age. In very young children, the doses 
given at first should always be watched with a good deal of care, and 
never carried to such a quantity, or continued long enough, to induce 
constant and heavy drowsiness or stupor. In some instances of very 
nervous and hyperaesthetic children, in whom there is determined, by the 



USE OF OPIUM — GENERAL MANAGEMENT. 187 

violence of the reaction, a degree of irritability of the nervous centres 
tending to the tetanic state, the doses must be much larger than those 
mentioned; but here the physician should see the patient himself at least 
twice, and sometimes three times in the da} T , to watch and regulate by the 
dose the exact action of the drug. We have occasionally seen the cough 
most harassing and exhausting in its effect, occurring almost with every 
breath, and lasting for twelve and twenty-four hours. Under such cir- 
cumstances, a mixture like the following has proved most beneficial in 
our hands : 

R. Tr. Opii Deodorat., . . gtt. xxxij. 

Tin. Antimon., ........ gtt. xxxij. 

Ext, Valerian. Fl., fgij. 

Syrup. Simp., fgij. 

Aqua?, f^iss. — M. 

Dose, a teaspoonful every hour or two hours, at the age of four years and upwards, 
until the cough is controlled. 

Paregoric, in the proportion of two drachms to half an ounce, in place 
of the laudanum, sometimes proves more soothing and comforting. 

General Management. — Since the reign of restorative medicine has 
set in, the general management of the patient has received a degree of 
attention which it had never attracted before. Under the expectant plan 
it constitutes, indeed, the chief portion of the treatment. The most 
important points to be attended to under this head are the diet, drinks, 
clothing, air, and state of repose. 

The patient ought not to be allowed to go entirely without food even 
in the early da}~s of the disease, neither should there be any effort made 
to stuff the child with large quantities of nourishment. The appetite is 
nearly always in great measure abolished, at first, and food is unwillingly 
taken except in very small quantities. A nursing child must not be 
allowed to nurse as heartily as usual. If it attempts to do so, it is prob- 
ably from thirst and not from hunger. Water, therefore, should be offered 
to it from time to time, and the breast be allowed only eveiy three or four 
hours for short periods. Weaned children should have only milk, alwa} T s 
reduced by the addition of half or a third water, and pure water ought 
to be given frequently. The thirst in this disease is intense, and the 
physician should himself see that the patient has water freely. We have 
seen the most violent and obstinate screaming, and painful restlessness, 
quieted at once by a copious draught of cold water. In children over two 
and three years of age, milk and water is still the best food ; but when 
this is refused, thin chicken or beef-tea may be given in doses of a wine- 
glassful or a gill every four hours. After three or four days have passed 
by, the administration of food is a very important part of the treatment. 
The child should now be induced, by persuasion and even gentle force, 
to take a little food at least three or four times in the twenty-four hours. 
As the severhYy of the symptoms subsides, the food ought to be increased 
in quantity. 

The clothing ought to be such as to keep the body comfort ably warm. 
In winter, which is the season when the disease almost always occurs. 



188 BRONCHITIS. 

thin and soft flannels ought to be worn, and, when the child is very rest- 
less, either in the bed or on the lap, a sack made high in the neck, with 
the sleeves to the wrists, buttoning in front and consisting of a soft and 
pliable woollen stuff, ought to be put over the bed-dress. 

The room ought to be, if possible, a large one with a high ceiling, well 
ventilated, warmed by an open fire, and kept at a temperature of 65° to 
68°. If the child is very j'oung and delicate, a temperature of T0° is not 
too high, if only the ventilation be good. 

The bed or crib is the proper place for a child with pneumonia. The 
lap of the mother or nurse is a poor substitute for an even, elastic, and 
stead}' mattress. We have long endeavored to keep our little patients in 
bed. A very young infant must of course often be taken up to be nursed, 
soothed, or cleansed, but, as soon as possible, it ought to be replaced in 
the crib. Children a } T ear or two old can generally, with good manage- 
ment, be kept the greater part of the time in bed. Those of three and 
four years old and upwards ought always to be confined to the bed. A 
little firmness on the part of the mother will almost alwaj^s accomplish this 
end, and it is a highly important one, and well worth even a quarrel at 
the beginning of the sickness. We have seen a child three years old kept 
by a weak and over-tender mother and grandmother nursed on the lap 
for three weeks, until the}^ were exhausted and demoralized, and the 
child had cedematous feet from their dependent position during so long 
a time. 

Eepose and quiet of mind and body, as complete as can be attained, 
are things of great value, and to secure them a good bed and a cheerful 
and resolute manner on the part of the nurse are as important for the 
child as for the adult. It is only in bed, too, that an even temperature 
and an avoidance of draught can be fully secured. A direction given by 
some of the French writers, and b}^ Dr. Gerhard, is not to allow very 
young children to lie for too long a time in one position in bed, or in the 
nurse's arms, as it is apt to produce a stasis of blood in the dependent 
portions of the lungs, and thus to maintain or increase the disease. Dr. 
West recommends, whenever the inflammation has reached an advanced 
stage, or involved a considerable extent of the lungs, that the patient be 
moved with great care and gentleness, lest, as he has often seen occur, 
convulsions be produced. 



AKTICLE III. 

BRONTCHITIS. 

Definition; Synonymes; Frequency; Forms. — The term bronchitis 
is now universally employed to express inflammation of the mucous mem- 
brane of the bronchia. 

It is usually called in this country catarrh, and catarrhal fever. It has 
been stated, under the head of Pneumonia, that many of the cases known 



FREQUENCY — CAUSES. 189 

amongst us by the popular term catarrh-fever, are, in fact, cases of pneu- 
monia. "We shall on account of this misapplication of names, endeavor 
to draw the distinction between bronchitis and pneumonia with great 
care. Bronchitis is not treated of either by Dewees or Underwood. Dr. 
Eberle confounds it with pneumonia, under the titles of catarrh, catar- 
rhal fever, acute bronchitis, and plenritis. 

Since the distinction between bronchitis and pneumonia has been more 
carefully drawn in the mortality returns of this city, bronchitis is found 
to be the cause of a much smaller proportion of deaths than would have 
formerly appeared. 

Thus, during the past seven years, the total mortality from all causes 
(excluding still-born children) was, at all ages, 105,785 ; under fifteen 
years of age, 50,151 ; and under five years, 43,322. The mortality from 
bronchitis during this period was, at all ages, 969, or less than 1 per cent, 
of the entire mortalit}' ; under fifteen years, 509 or 1.01 per cent, of the 
mortality under that age; and under five years, 495, or 1.14 per cent, of 
the mortality under that age. 

It is, however, one of the most frequent of the diseases of childhood, 
especially during the winter and early spring months. It is said to be 
more common as a secondary than as an idiopathic disease. Of 115 
cases observed b}* MM. Rilliet and Barthez, only 21 were idiopathic. Of 
123 cases, however, that we have recorded, 76 were primary, and the re- 
maining 47 secondary. The diseases during the course of which it is 
most apt to occur, are pertussis and measles. 

We shall describe three forms of the disease: 1, acute bronchitis of 
moderate severity ; 2, acute suffocative bronchitis, or catarrhus siuToea- 
tivus, the congestive catarrhal fever described by Eberle and by Dr. 
Joseph Parrish, of this city; 3, subacute or chronic bronchitis. 

Causes. — Amongst the predisposing causes of the disease, age is one 
of the most important. MM. Rilliet and Barthez suppose it to be much 
more common in children over, than in those under five years of age. Of 
one hundred and fifteen cases observed by them, thirty-seven occurred 
between the ages of one and five years, and seventy-eight between six 
and fifteen years of age. It is scarcely fair, however, to compare a period 
of nine years with one of only four, as is done in the above statements. 
Of one hundred and twenty cases that we have seen in private practice, 
in which the age was noted, fifty-four occurred between birth and two 
years of age ; thirty-nine between two and four years ; twelve between four 
and six ; six between six and ten ; and three between ten and fifteen. Of 
eiglurv-one cases under four 3'ears of age, of which we have kept an ac- 
curate record, eleven occurred in the first half of the first year of life, 
twenty in the second half, making thirty-one for the first year ; twenty-one 
occurred in the second year of life, nineteen in the third, and ten only 
in the fourth, showing that the liability is greatest in the first year of lite, 
and particularly in the last half of that year, that it continues very strong 
in the second and third years, being nearly equal in each of these, and 
that it then suddenly diminishes. It would seem also that the simple 



190 BRONCHITIS. 

acute, and the acute suffocative forms are most common under six 3 r ears 
of age, while the secondary cases occur more frequently after that age. 

As to the influence of sex on the liability to the disease, it would appear 
from our experience to be rather more common in girls than bo} T s, since 
of ninety-nine cases in which this point was noted, fifty-four occurred in 
girls, and forty-five in boys. The fact of its being more frequently a 
secondary than a primary affection, has already been noticed, though 
this has not been true of our experience. The diseases in which the 
largest number of cases occur are measles, pertussis, and typhoid fever. 
The secondary cases are most common, of course, during the prevalence 
of the diseases whose progress they complicate, whilst the primary cases 
are most common in the cold months of the year, and especially in the 
autumn and spring. The reader is referred to the table in the article on 
pneumonia for a full exhibition of the effects of season and temperature 
upon the frequency of this disease. Bronchitis is sometimes epidemic 
amongst children as it is amongst adults. 

The only exciting causes whose effects in the production of the disease 
seem clearly proved are sudden transitions from a warm into a cold at- 
mosphere, and sometimes the contrary change; prolonged exposure to 
cold, particularly when combined with moisture ; and the inspiration of 
irritating gases. We believe ourselves, from what we have seen in this 
city during the last twenty years, that the most fruitful cause of bron- 
chitis, and also of pneumonia, croup, and angina in early life, is the style 
of dress almost universally used for young children. The dress is en- 
tirely insufficient. It consists usually of a small flannel shirt, cut very 
low in the neck, scarcely covering the shoulders, and without sleeves ; of 
a flannel petticoat, a muslin petticoat, and an outer dress made in nearly 
every case of cotton. The dress, like the flannel shirt, is cut low in the 
neck, is without sleeves, and fits very loosely about the chest, so that not 
only are the whole neck, the shoulders, and the arms exposed to the air, 
but, in consequence of the looseness of the dress about the neck, it is fair 
to say that the upper half of the thorax is also without covering. In the 
infant, from birth to the age of six or eight months, the dress is made 
long, a wise provision so far as it goes, but from the time the skirts are 
shortened, up to the age of four or five 3-ears in boys, when happily the 
time for bo3 r s' clothes arrives, and, throughout childhood in girls, the 
trunk of the body and the arms are dressed, or rather, left undressed, as 
above described. But, not only are the neck, breast, and arms left bare, 
but in maiy children the greater part of the legs also are kept uncovered, 
or, at least, short stockings, scarcely rising above the ankles, and muslin 
or sometimes Canton flannel drawers, not reaching, or scarcely reaching 
to the knees, leave exposed to the air a large proportion of the cutaneous 
surface of the lower extremities. Now, in this dress, the child passes the 
da}^ in a house, the sitting-rooms of which are heated usually to 68° or 
*70°, but in which the entries, and sometimes the parlors, are frequently 
at a temperature of 60 c , 50°, or even lower, as we ourselves have tested 
with the thermometer. And not only are the entries and parlors, and 
indeed all the rooms, saving the one or two in constant use, frequently 



EFFECT OF INSUFFICIENT CLOTHING — ANATOMICAL LESIONS. 191 

at the temperature just mentioned, but the air of the nursery itself is 
often allowed, through the negligence of the servants, and especially early 
in the morning, to fall to 60° or 58°, or possibly lower still. 

That this style of clothing is not correct, is proved by the simple facts 
that children who are dressed nearly the same in summer as in winter, 
suffer scarcely at all from colds in the summer season, when the ther- 
mometer seldom ranges below 16°, and is usually above that point; and 
also by the fact that adults have been driven b} T long and almost forgot- 
ten experience, to wear clothing twice or three times as warm as that 
which they put upon their children. How constantly do we see the 
strong and fully-developed man comfortably enveloped in a warm, long- 
sleeved flannel shirt, woollen or thick cotton drawers, and cloth panta- 
loons, vest, and coat, in the same room and in the same temperature with 
the little — often puny, pale, and half-naked — child. But it is almost im- 
possible to make people understand that children need as much clothing 
as themselves. The}' always insist upon it that, as the child passes the 
greater part of the day in the house, it cannot require as much clothing 
as the adult who is obliged to go out and face the weather; forgetting, or 
refusing to see, that the former wears less than half, or probably not more 
than a fourth, as much covering as the latter, and that the adult, when 
in the house, and in the same rooms as the child, finds his one-half or 
three-fourths warmer clothing not at all superabundant or oppressive. 

We have repeatedly had patients to get well of chronic catarrhal and 
laryngeal coughs, and to cease to have, as before, frequent recurrences 
of these disorders, under the simple treatment of a long-sleeved and high- 
necked merino or flannel shirt ; long woollen stockings, and stout Canton 
flannel drawers coming down below the knees ; and that, too, after the 
most patient and assiduous, and sometimes over assiduous trials of drugs, 
diet, and confinement to the house, had entirely failed of any permanent 
good effects. The fact is, that though there are some few children who 
can bear the dress above-described without injury, there are a great many 
more who, while they wear it, either suffer all winter long from frequently- 
repeated attacks of cold, in the shape of croup, chronic laryngeal irrita- 
tion with cough, chronic pharyngitis, bronchitis, acute or chronic, or 
more rarely pneumonia ; or, if they escape these direct effects, resulting 
from the constant and rapid waste of their caloric, they are rendered 
more pale, thin, and delicate-looking than they would be were their vital 
forces husbanded by warm clothing, instead of being wasted in the con- 
stant struggle to keep up the heat of the uncovered body at the natural 
point. 

Anatomical Lesions. — We shall describe, first, the lesions met with 
in cases in which the disease is confined to the larger bronchia, the in- 
flammation not extending into the capillary tubes; and next, those ob- 
served in cases in which the disease has attacked the capillary bronchia. 
The former are those which constitute the form designated under the 
title of acute, ordinary bronchitis, of moderate severity, while the latter 
are those to which the term capillary has been applied. Patients seldom 
die of the first-named variety of the disease alone, but as it often occurs 



192 BRONCHITIS. 

as an accidental complication, or a more or less essential part of differ- 
ent severe and frequently fatal diseases, the morbid alterations which 
characterize it, have been very thoroughly studied and ascertained. 

The morbid alterations of acute ordinary bronchitis alwa}~s exist in 
both lungs, and are confined to the larger bronchia, ceasing on a line 
with the smaller tubes and the capillary divisions. The most constant 
alteration is redness of the bronchial mucous membrane, caused by injec- 
tion of the minute vessels of that and the subjacent tissues, and varying 
in shade from a rosy to a bright-red or brownish tint. The mucous mem- 
brane is sometimes softened, a change which can be ascertained only in 
the largest tubes, and it sometimes presents a thickened, unequal, and 
rough appearance. Ulcerations are very rare. The inflamed bronchia 
contain a more or less abundant viscid, transparent, or opaque }*ellow- 
ish mucus. 

In capillary bronchitis the alterations of the mucous membrane of the 
capillary tubes, do not always reveal the existence of the disease. That 
membrane is sometimes pale in the minute ramifications, and exhibits 
morbid changes only in those of medium size. The alterations of the 
membrane consist in redness, which is made up either of a number of 
fine points, seated in the membrane itself, or of arborizations seated both 
in the membrane and the cellular tissue beneath; it sometimes presents 
a granulated appearance, and it may be more or less thickened, and its 
consistence diminished. The bronchia are usually filled and almost ob- 
literated from the secondary divisions to the final ramifications, hy a sub- 
stance of a yellowish-white or yellow color, non-aerated, and composed of 
a thick muco-pus. Portions of false membrane are sometimes, not as a 
rule, but exceptionally, found mixed with the secretions just described, 
while in other instances false membranes alone are present in certain 
tubes. The false membrane msij exist in the form of patches, or it may 
constitute a lining to the \vhole extent of the bronchial ramifications. It 
is usually soft and but slightly adherent, and the mucous membrane be- 
neath is either very pale and of its usual consistence, or red, softened, 
and rough. The different kinds of secretion are commonly most abund- 
ant in the bronchia of the inferior lobes. 

In a good many of the cases, another lesion, dilatation of the bronchia, 
is also found upon examination. This alteration evidently occurs under 
the influence of the inflammation; it may affect either the length of the 
air-tubes, or only their extremities. In the former condition the tube 
continues of the same size, or becomes gradually larger from one of its 
early subdivisions, until it reaches the surface of the lung. In the latter 
condition a section of the lung presents an areolar appearance, from the 
presence of a multitude of little rounded cavities, communicating with 
each other and with the bronchia, of which they seem to be a continua- 
tion. These cavities are generally central, though they are sometimes 
found upon the surface of the lung, in which case they are formed of the 
pleura, lined by the thinned membranes of the dilated bronchus. 

The fact of these cavities being true dilatations of the bronchia, has 
been called in question by Dr. Gairdner (loc. cit., p. 76), who believes, on 



ANATOMICAL LESIONS. 193 

the contrary, "that almost all the so-called bronchial dilatations, and all 
of those presenting the abrupt, sacculated character here alluded to, are 
in tact the result of ulcerative excavations of the lung communicating 
with the bronchia." He supposes them to be the result of the expansion 
of certain small cavities, frequently met with in the bronchitis of children, 
and to be described directly under the title of vacuoles or bronchial ab- 
scesses, either by ulceration or by the act of inspiration. 

In addition to the lesions already described as existing in bronchitis, 
there is another one, not unfrequently met with, to which I shall call 
attention, that to which the French writers apply the term vacuoles, and 
which Dr. Gairdner designates as bronchial abscess. The latter author 
states that in the centre of the collapsed lobules of a lung affected with 
acute bronchitis, there are found, not unfrequently, small collections of 
pus, varying in size from that of a hemp-seed to double or treble that 
volume. " These small abscesses present, on section, an appearance so 
much like that of softening tubercles, as to be very readily mistaken by 
many persons for these bodies ; and the resemblance is all the greater on 
account of the peculiar limited form of the condensation by which they 
are generally surrounded, which, when felt by the touch from the exterior 
of the lung, is exceedingly deceptive. In their interior, however, these 
little abscesses contain, in the recent state, a very fluid pus ; moreover, 
the}' are often met with as acute lesions produced by a few days of ill- 
ness, and without a trace of tubercle in any other organ." When the 
pus is scraped or pressed out of these abscesses, in their recent form, 
they are found to be lined with a fine villous membrane, while in other 
instances they are not abruptly limited, but the pus appears to lie in 
contact with the surrounding pulmonary tissue. The bronchia leading 
to the part of the lung thus affected, are found, when incised, to be much 
inflamed, their mucous membrane being vascular, thickened, and covered 
with pus ; and some of them can be observed to communicate with the 
purulent collections, the mucous membrane having been, at the point of 
communication, destroyed by ulceration, and either stopping short ab- 
ruptly, or becoming gradually incorporated with the false membrane 
lining the abscess. Sometimes these abscesses or vacuoles communicate 
not only with the bronchia, but also with each other, without difficulty ; 
sometimes, according to Dr. Gairdner, they break into one another and 
form more considerable excavations, but, more commonly, they remain 
of limited size, preserving perfectly the direction and relations of the 
bronchial tubes. They occur both in the diffused and lobular form of 
condensation from collapse of the lung, and both forms may sometimes 
be seen in the same lung. 

The alteration just now described has excited a good deal of discussion 
amongst medical writers, and has been very differently accounted for. 
MM. Rilliet and Barthez regard it as a simple terminal dilatation of the 
bronchia, while MM. Barrier, and Legendre and Bailly, consider it to 
depend on a purulent breaking down of the vesicles of one or more 
lobules. MM. Hardy and Behier look upon it as a lesion of a complex 
nature, partaking both of dilatation of the bronchia and of pulmonary 

13 



194 BRONCHITIS. 

emphysema. Dr. Gairdner, as already mentioned, describes them as 
abscesses, and states that they " unquestionably arise from the accumu- 
lation of pus primarily in the extreme bronchial tubes of the collapsed 
lobules." This view, which is closely similar to that of MM. Barrier, and 
Legendre and Bailh T , is, it appears to us, much the most reasonable that 
has been adduced. 

MM. Rilliet and Barthez, in their second edition, as has already been 
stated, in the article on post-natal collapse, describe at great length a 
state of congestion of the lung-tissue, as a most important element in the 
anatomical alterations of the bronchitic diseases. This congestion usually 
assumes one of two forms : it may be distinctly lobular, consisting then 
of disseminated patches, or, as more generally happens, large numbers 
of contiguous lobules are affected, when it takes the form of generalized 
lobular congestion. These congested portions of the lung are almost 
always attended with more or less well-marked collapse of the vesicles, 
so that there is associated together the conditions of congestion and col- 
lapse. It is this combination of bronchitis with congestion and collapse, 
which was formerly described by them, under the titles of lobular and 
generalized lobular pneumonia. The alteration to which the term carni- 
fication has been applied, and which not unfrequently coexists with 
bronchitis, they regard as different from the above, and as consisting in 
a simple collapse of the lung-tissue, without the active or passive con- 
gestion which exists in the first form. The principal causes of this con- 
dition are, according to them, debility and catarrh. The signs of catarrhal 
inflammation are, they state, never scarcely absent. In only four out of 
thirty-one cases did they fail to discover them. 

The parenclryma of the lung presents, in bronchitis, different appear- 
ances in different cases. It is supple, crepitant, and of a rose-gray color, 
but does not collapse, especially the anterior portions, when the thorax 
is opened, as does healtlry lung. This imperfect collapse depends either 
on the fact that the thick mucus and muco-pus which fill and obstruct 
the bronchia, prevent the contained air from being expelled by the natural 
elasticity of the lung, or, when no secretions exist to produce this effect, 
on the loss of the natural elasticity of the organ. Another cause is the 
existence of vesicular eroplrysema, a lesion observed to a greater or less 
extent in nearly all the cases, and affecting usually the summit of the 
lung, its anterior edge, and also its posterior or lateral edge. In a large 
number of cases, and particularly in those occurring in young children 
and in weakly and debilitated subjects of all ages, the tissue surrounding 
the diseased bronchia exhibits the condition which has already been fully 
described in the article on atelectasis, under the title of collapse of the 
lung. The extent and mode of distribution of this lesion, its peculiar 
and distinguishing characters, its causes and mode of production, and 
the method of treating it, have been carefully treated in the article just 
referred to, and we shall make no further allusion to it, in this place, 
except to beg the reader, who is not already fully acquainted with it in 
all its bearings, not to suppose himself master of the subject of bronchitis 
until he has also fully studied that of collapse, as the two go together so 



SYMPTOMS. 195 

constantly, and the latter is practically so important, especially in chil- 
dren, as to make it essential for him to understand both. 

The lesions just described as characteristic of acute bronchitis, are also 
met with in the chronic form of the disease. The dilatation of the air- 
tubes, however, presents different features. The calibre of the enlarged 
tube is often much greater, its walls are whitish and uneven, and cry under 
the scalpel, and beneath the mucous lining may be seen hypertrophied 
transverse fibres. The mucous membrane itself remains smooth and 
polished, while the tissues beneath are thickened and hypertrophied. 

Symptoms ; Course or the Disease ; Duration. — Acute simple bron- 
chitis exhibits very different degrees of severity in different cases, being 
in some extremely mild and benign, and in others so much more severe, 
as to border closely on the capillary form of the disease. In its mildest 
form, it occasions merely slight cough and stuffing, a little mucous rale 
over the larger bronchia, with a total absence of dj^spncea, or of decided 
fever. In cases rather more severe than this, it begins with a moderately 
frequent cough, which, dry at first, soon becomes loose, and is neither 
paroxysmal nor painful. The expression of the face remains natural, 
with the exception of an appearance of slight languor. The pulse and 
respiration are but slightly accelerated ; the external phenomena of the 
latter, an important means of diagnosis in infants, remain natural ; it oc- 
curs without jerking, the rlrythui continues even and regular, and there 
is no violent action of the ahe nasi. The percussion is not modified. 
Auscultation reveals in very young children a mixture of mucous and 
sibilant rales on both sides, which come and go, and are of short duration ; 
in older children, the moist rales predominate, and commonly last several 
days. These sounds are seated in the larger bronchia. The temper of 
the child is not much changed ; the appetite is not entirely lost ; there is 
neither vomiting nor diarrhoea ; and the fever is usually slight. The dis- 
ease remains nearly stationary, or increases for a variable length of time, 
after which the cough becomes looser, and in children over five years of 
age, is sometimes attended with expectoration of frothy or yellowish mu- 
cous sputa, whilst under that age there is no expectoration. The fever 
and other symptoms, with the exception of the cough, now subside ; the 
cough remains some days longer. 

In attacks still more severe than this, the symptoms resemble very much 
those just now described, but they are all more intense. The cough is 
tighter, more frequent, harassing, and especially it is more painful, as 
shown by the fact that the child cries and complains, and that a marked 
expression of pain passes over the face at the instant of coughing. There 
is more fever, the skin being hot and dry, and the pulse more frequent, 
rising often to 130 or 140, and in one case to 156. The respiration is 
hurried, and though not attended with the same labor and anxiety as in 
the capillary variety, it is evidently oppressed ; it counted in three eases, 
60, 60, and 62. There is more restlessness, fretfulness, and general dis- 
tress ; the appetite is greatly diminished or lost, and infants nurse with 
less avidity than usual, or refuse to nurse at all for several hours together. 
In cases of this kind, the physical signs are more decided than in those 



196 BRONCHITIS. 

of milder degree, there being a greater abundance of mucous and dry 
rales, and generally some subcrepitant rale, and they are heard over a 
larger extent of surface, usually over the lower half, two-thirds, or even 
the whole dorsum of the chest. The symptoms are almost always most 
marked and severe in the after-part of the day and night. Yery often 
the patient will be comparatively easy and comfortable in the morning, 
but as the day goes on, he becomes more feverish, restless, and fretful ; 
the cough grows more troublesome, more frequent, and tighter; the 
breathing is quicker and more oppressed ; the face is more flushed ; the 
sleep is broken and disturbed, and the child ma} 7 appear through the night 
quite ill; and }^et as morning approaches, the symptoms moderate, the 
skin often softens and becomes moist, and the whole aspect of the case 
shows a great amelioration in the manifestations of the disease. 1 

The duration of this form of bronchitis is very uncertain ; the idiopathic 
cases last usually from four to seven or eight days, though they may last 
from sixteen to twent3'-five ; the duration of the secondary cases depends, 
in great measure, on the nature of the diseases during which they occur. 

In airy of these different degrees of acute simple bronchitis, the patient 
is liable, especially if it be a weak and debilitated child, or a young in- 
fant, to sudden and alarming aggravations of the symptoms. The breath- 
ing becomes suddenly either greatly increased in frequencj^, or exces- 
sively labored and oppressed, the surface becomes pale, the expression 
dull and languid, or distressed, the child is drows}^ and inattentive, or 
uneasy and restless, the hands and feet are coolish, the act of sucking is 
performed with difficult}^, or the child refuses the breast entirely, and it 
is evident that, from some sudden change in the condition of the lungs, 
the act of respiration and the aeration of the blood are very seriously in- 
terfered with. If this sudden aggravation of the symptoms be unattended 
with a corresponding increase of the febrile phenomena, as marked by 
greater heat of skin and augmented action of the circulation, it is alto- 
gether probable that it depends on a collapse of larger or smaller portions 
of the pulmonary texture, and if, on examination, we discover dulness 
on percussion, distant bronchial respiration, and cessation, or greatly 
diminished abundance of the bronchitic rales, over parts of the chest 
where a few hours or a day before there had existed all the physical signs 
of bronchitis, there can be no longer any doubt as to the cause of the 
suddenly increased severity of the symptoms, — it must be owing to col- 
lapse. 

Acute suffocative bronchitis, capillary bronchitis, or the congestive 
catarrhal fever of Parrish and Eberle, and the suffocative catarrh, or 
bronchial croup of other writers, may succeed to the form just described, 
or appear as an idiopathic affection. Under either condition the general 

1 According to Handfield Jones, this almost invariable tendency to aggravation of 
catarrhal disorders during the night is due to a lowering of the nerve-power, the vaso- 
motor nerves partaking of the general debility, and thus allowing dilatation of the 
arteries, and causing increased hyperemia of the affected parts with more abundant 
exudation. 



SYMPTOMS OF CAPILLARY BRONCHITIS. 197 

symptoms are more threatening than in the preceding form, and the 
disease soon assumes all the appearances of great severity. The child is 
very uneasy and restless, constantly changing its position, moving about 
in the crib or bed, or insisting upon being changed from the bed to the 
lap, or from the lap to the bed. In one case that came under our charge 
the oppression was very great, and the only position in which the child 
was at all satisfied was resting on the mother's arms, with the front of its 
chest applied against the mother's breast, and the head hanging over her 
shoulder. The expression of the face is anxious and disturbed, and its 
color usually pale or slightly bluish. The temper is irritable or subdued ; 
the child hates to be disturbed, and generally chooses its own position. 
The respiration is very much accelerated, running up in a very short time 
to 60, TO, or 80, and it is usually more or less irregular, and evidently 
laborious and difficult. The cough is very frequent, troublesome, and 
evidently painful ; it occurs in short paroxysms usually, with or without 
stridulous sound, is at first dry, and after a few days is accompanied, in 
older children, by whitish or yellowish expectoration. In some instances, 
the sputa consist of mucus tinged with blood, or of pure blood even, and 
still more rarely of mucus mingled with small shreds of false membrane. 
The appetite is entirely lost ; the tongue is usually moist and furred white ; 
there is acute thirst, and } T et, in severe cases, though the presence of 
acute thirst is evident from the manner of the child, only very small 
quantities of water are taken, from the impossibility of suspending the 
respiration long enough to allow of more being swallowed ; the drink is 
gulped rapidly, suddenly, and with great difficulty, and after a time is 
refused almost entirely from this cause. In children old enough to talk, 
the speech is short and abrupt ; the patient dislikes to speak, from the 
fact that the effort obliges it to suspend momentarily the act of breathing. 
Fever sets in from an early period ; the skin is hot and dry, and the face 
is flushed at first, though it soon becomes pale in most cases, from the 
approach of an asphyctic state. The pulse becomes frequent, rising soon 
after the onset to 130, 140, 150, or higher ; it is full and hard early in the 
attack. The resonance on percussion is not modified. Auscultation 
reveals at first sibilant rale, mixed with some mucous rhonchus ; but soon 
a fine subcrepitant rale is heard over all the lower parts of both lungs 
behind, and approaching, sometimes, over the bases of the lungs, the 
character of crepitus. After a time the subcrepitant rale is heard over 
the whole, or nearly the whole dorsum of the chest, and to a greater or 
less extent, though not so well marked as behind, over the anterior 
regions of the thorax. This rale is audible at first both in inspiration 
and expiration, and is very distinct, but at a later period, it is heard only 
in the inspiration, or there is substituted for it a mucous rale, while the 
subcrepitant rale is now heard only in the forced inspirations during 
coughing or crying. These rales are fugitive and irregular, disappearing 
or changing from one to the other after fits of coughing. 

Should the case not take a favorable turn, which change would be in- 
dicated by a moderation in the sjanptoms just detailed, and especially by 
easier and fuller respiration, with diminution of the amount of the sub- 



198 CHRONIC BRONCHITIS. 

crepitant rale, and return of the natural respiratory murmur over some 
parts of the chest, the symptoms look still more alarming. The oppres- 
sion becomes excessive ; fits of clvspnoea occur, in which the child is ex- 
tremely restless and distressed, tossing itself about on the bed; the respi- 
ration runs up to 80, 90, or more, in the minute, and is attended with 
violent action of the alse nasi; the pulse grows more and more fre- 
quent, rising to 150 or 180, and it loses force and volume; and the face 
assumes a whitish or slightly bluish tint, looks puffed, and is sometimes 
covered with perspiration. As the fatal termination approaches more 
nearly, the pulse becomes small, thready, and irregular ; the respiration 
is uneven, irregular, stertorous, and often slower than before ; the cough 
is smothered and less frequent; the restlessness generally diminishes, 
and the child sinks into quiet, and often becomes comatose : the par- 
oxysms of suffocation are less frequently renewed, and less violent, and 
death occurs in a state of quiet insensibility, or is preceded hj partial or 
general convulsive movements. 

The duration of this form may be stated to be, on the average, between 
five and eight clays. It ma} 7- , however, end fatally in a much shorter time. 
In an example that we saw, in a child four months and a half old, death 
occurred in twenty-six hours from the onset. Dr. Eberle states that it 
seldom lasts longer than two or three days, and that in very young in- 
fants death sometimes occurs on the first day. M. Bouchut gives us the 
duration in children at the breast, from two days to a week. Dr. West 
mentions a case that proved fatal in less than forty-eight hours. In the 
favorable cases that we have seen the duration was seven, eight, and ten 
days. 

Subacute and chronic bronchitis generally follows one of the acute forms 
of the disease. The character and severity of the symptoms vary very 
much in different cases. -We have known some children to present for 
several months together, in the winter season, slight bronchitic symp- 
toms, consisting in wheezing and somewhat accelerated breathing ; cough, 
more or less frequent ; occasional feverishness, especially at night ; some 
diminution of appetite and loss of flesh ; and sibilant and sonorous with 
mucous rales, heard here and there, but still without severe S3'mptoms 
during the greater part of the time. Children laboring under this kind 
of bronchitic irritation are liable to, and generally have, from time to 
time, more or less sharp attacks of acute bronchitis, in which they pre- 
sent the usual symptoms of that form of the disease. These attacks are 
very apt to occur coincident^ with changes in the weather, and in some 
patients the liability to them is so great, from the excessive susceptibility 
of the s} T stem to the weather, that no care will prevent them. In some 
instances, we are very sure that an aggravation of the symptoms of the 
chronic form constantly occurs whenever the child is about cutting 
additional teeth, whilst in the intervals between the appearance of the 
successive teeth, the child remains comparatively well. We believe that 
the cause of the aggravation, at the moment of cutting the teeth, is to 
be looked for, not in the act of dentition itself, but in the circumstance 
that the liability to cold is greatly increased at that particular moment, 



PHYSICAL SIGNS. 199 

probably because the forces of the system are so weakened by the effort 
of the dentition as to lessen the power of resistance against the disturb- 
ing iufluence of a changing, and particularly of a falling temperature. 

Cases of the mild kind of chronic bronchitis that we have just been de- 
scribing, usually get well under proper medical, and especially under 
proper hygienic means, after several weeks or two or three months ; while 
in other instances the disorder continues, in spite of every precaution, 
throughout the winter and spring, and only ceases as the warm summer 
months arrive. We have known the same disposition to show itself again 
in the following winter. In other instances again, the frequent attacks 
of severe bronchitis, together with the effect of a constant slight bron- 
chitic inflammation, ends in the production of an emphysematous state 
of parts of the lung, and the child exhibits more or less marked asth- 
matic symptoms, which show themselves whenever a slight increase of 
the bronchitis occurs, and whenever the digestive system is deranged by 
imprudence in diet or other causes. 

In other examples of chronic bronchitis the symptoms are much more 
severe. These cases almost alwaj's follow an acute attack of the disease. 
The frequency of the respiration and the attacks of dyspnoea persist ; the 
cough is loose and paroxysmal, and the pulse frequent and small ; even- 
ing exacerbations of fever take place, and the face and sometimes the 
rest of the surface are often covered with perspiration. Auscultation re- 
veals tubal blowing, with mucous or loud sonorous rhonchus, which seem 
to indicate the presence of dilatation of the bronchia. Emaciation makes 
rapid progress, the face is pale and blanched, the eyes sunken, the nostrils 
are covered with mucous or blood}^ crusts, and the lips ulcerated. Strength 
diminishes progressively ; the appetite is lost, and the thirst acute ; colli- 
quative diarrhoea appears ; and after twenty, forty, or more days, the 
child perishes in the last stage of marasmus. This form of bronchitis 
often simulates phthisis very closely, and may last for a long time, even 
several years. It rarely occurs under the age of five years. The expec- 
toration consists of purulent or pseudo-membranous secretions in vari- 
able quantity. 

Particular Symptoms — Physical Signs. — The dry rales are amongst 
the most frequent alterations of the respiratory sound in bronchitis. 
They may be sibilant or sonorous ; they seldom exist alone, but are ac- 
companied with mucous rale, and diminish as the latter becomes more 
abundant. As the dry rales cease to be heard, they are replaced by mu- 
cous or subcrepitant rales, or by feebleness of the respiratoiy murmur. 
The sibilant rale is often heard over the whole thorax, though it may be 
confined to the posterior portions. It is not restricted to cases of inflam- 
mation of the larger bronchia only, but is also present in capillary bron- 
chitis. 

Humid Bales. — Mucous and subcrepitant rales do not exist in all cases 
without exception, as they may be absent in such as are very mild. They 
may generally be heard over both sides behind, more rarely over the 
whole of the chest, and almost alwa3'S both in inspiration and expiration. 
The} r are generally persistent, but are sometimes suspended lor a moment 



200 BRONCHITIS. 

and replaced by sibilant rhonchus or feeble respiratory sound. Their 
duration is in proportion to that of the disease. 

Feeble respiratory murmur is sometimes observed. It is not perma- 
nent, occurs during the interruptions of the subcrepitant or sonorous 
rale, and does not occupy the whole extent of the thorax, but is limited ; 
it is intermittent, and is not accompanied by diminished resonance. 

When dilatation of the bronchia exists to a considerable extent it gives 
rise to bronchial or even cavernous respiration, and to bronchial reso- 
nance of the voice, cry, and cough. The bronchial respiration differs 
from that of pneumonia b}^ its tone, and b}^ its intermitting. The percus- 
sion is generally sonorous. 

It has already been stated in the account of the symptoms that it hap- 
pened not unfrequently in severe bronchitis, and also in mild bronchitis 
occurring in debilitated children, that the respiratoiy sound suddenly be- 
came feeble, or even entirely suppressed, over parts of the lung, while in 
other instances a distant and imperfectly marked bronchial respiration 
takes the place of the natural vesicular murmur. These changes are 
heard either over small disseminated points of the lung, or over large 
surfaces ; they are associated with more or less evident dulness on per- 
cussion, and what particularly characterizes them, they are very fugitive, 
being present at one examination, and absent perhaps at the next. The 
appearance of these changes in the phenomena afforded by auscultation, 
were formerly thought to indicate the occurrence of pneumonia, and 
especially of lobular pneumonia ; they are now much more satisfactorily 
explained by the supposition that they depend on diffused or lobular col- 
lapse of the tissue of the lungs. 

The physical signs above described are not invariably present in bron- 
chitis. Cases do occur, though they are very rare, in which auscultation 
fails to reveal the presence of the disease. 

Rational Symptoms. — The rational s}'mptoms are of the utmost im- 
portance in informing us of the degree of severity of the attack. 

Cough generally exists from the beginning, being in mild cases more 
or less frequent, and either dry or loose, while in severe cases it is fre- 
quent or very frequent, at first dry and then moist, and very rarely hoarse. 
In acute capillary bronchitis, the cough has a peculiar character. From 
the first day it occurs in short paroxysms, lasting from a quarter to half 
a minute. The paroxj-sms vary greatly in violence, occur at irregular 
intervals, and generally continue without interruption to the fatal termi- 
nation, though they are sometimes replaced bj simple loose cough a few 
days before that event. The cough is rarely painful, so long as the in- 
flammation remains simple. Expectoration is never present in very 
young children. When it occurs in those over five years of age, it con- 
sists, in the mild form, of a sero-mucous or of a frothy and yellowish 
mucous liquid. In general bronchitis it is sero-mucous at first, becoming 
after a few da} T s }*ellowish and more or less viscous ; it is sometimes 
nummular, and sometimes amorphous. 

In the capillary form, as already mentioned, the sputa consist of mucus 
tinged with blood, or of pure blood even, and in some rare cases there 



RATIONAL SYMPTOMS. 201 

are mixed with the mucus, shreds of false membrane which may present 
the form of casts of the minute ramifications of the bronchial tubes. 

The respiration varies in its characters according to the extent and 
violence of the disease. In mild cases, it is not much increased in fre- 
quency, being generally between 28 and 40 in the minute. In more 
violent cases, and particularly when the disease implicates the smaller 
bronchia, it becomes very frequent. The acceleration is slight in the 
beginning, but increases regularly as the case progresses ; thus it may 
be 30 at first, and rise afterwards to 50, 60, 80, and even 90. When not 
very much quickened, it remains even and regular ; when more so, it 
becomes somewhat laborious, and the movements of the chest are full 
and ample ; in severe cases, attended with much dyspnoea, it is often 
irregular, or assumes the characters to which M. Bouchut has applied 
the term expiratory, that is, the order of the movements is inverted, each 
respiration beginning with the expiration, leaving a pause between the 
inspiration and expiration, instead of between the expiration and inspi- 
ration. In chronic bronchitis with copious purulent or pseudo-membranous 
expectoration, the dyspnoea is generally habitual. 

Fever. — -The fever is slight in mild cases, the pulse rising very little 
above its natural standard. The heat is not great, and the febrile move- 
ment usually subsides before the termination of the disease. In the 
grave or capillary form, on the contrary, the pulse is always frequent, 
and continues to increase in rapidity as the disease advances. It varies 
between 104, 120, 160, and in very violent cases, rises as high as 200. 
Earl} x in the attack, it is vibrating, rather full and regular, whilst in fatal 
cases, it alwa} T s becomes small, irregular, trembling, and unequal. The 
skin is generally hot in proportion to the activity of the pulse, except 
towards the termination, when the extremities often become cool. It is 
almost alwaj^s dry. In very young children it is often pale and cold, 
and covered with perspiration from the beginning. 

The expression of the face is unchanged in mild cases, but when the 
disease is violent and extensive, becomes deeply altered after a few da}^s. 
The eyes are then surrounded by bluish rings, and the expression is 
uneasy, anxious, and sometimes, but less frequently, exhibits an appear- 
ance of profound exhaustion. The anxiety of the countenance increases 
with the oppression ; the alae nasi are dilated, the nostrils dry or in- 
crusted, and the lips and face, which are extremely pale or momentarily 
congested, assume a purple tint, particularly after the paroxysms of 
cough. 

The decubitus is indifferent at first, but as the disease progresses, the 
child lies with its thorax more or less elevated, or is restless and con- 
stantly changing its position. 

In dangerous cases there is great distress and restlessness after the first 
few clays, or even from the beginning. In some instances the irritability 
and peevishness are excessive and uncontrollable, while in others there 
is heaviness and somnolence, especially towards the termination of fatal 
cases. Some of the disorders of the nervous system just mentioned are 
present in all the grave cases. 



202 - BRONCHITIS. 

Digestive Organs. — There is moderate thirst and incomplete anorexia 
when the disease is mild, but, when severe, the thirst is generally acute, 
and the appetite entirely lost. The state of the bowels varies. The 
tongue and abdomen present no special characters in idiopathic cases. 

Urine. — The great majorit}^ of recorded observations of the condition 
of this excretion in bronchitis, relate to the disease as occurring in the 
adult. The following summary is taken from Parkes : the condition of 
the urine in bronchitis varies greatly with the grade of the disease ; in 
the grave forms, it resembles that of pneumonia, the urea being in- 
creased, and the chloride of sodium at times entirely absent. The urine 
has also been quite frequently found to be temporarily albuminous in 
such cases. 

Diagnosis. — The mild form of bronchitis, in which the inflammation 
is confined to the larger bronchia, is not likely to be mistaken for any- 
thing but the early stage of hooping-cough. The diagnosis can be made 
only by attention to the different characters of the cough, which is more 
spasmodic and parox}^smal in pertussis, by the absence of fever in that 
disease, and by the development of the peculiar S3 T mptoms of each, as 
the case progresses. The diagnosis between bronchitis and pneumonia 
is seldom difficult, except when the latter is grafted upon the former, or 
in cases of partial pneumonia, attended with bronchitis. In well-marked 
cases of the two diseases, there can be no difficulty. The restriction of 
the physical signs to one side alone of the chest in pneumonia, the pecu- 
liar crepitus of that disease, or when this is not heard, the fineness of 
the subcrepitant rale, limited to the upper or lower regions of one lung, 
the bronchial respiration and bronchophony, the dulness on percussion 
over the seat of disease, the greater sharpness and severity and the 
different location of the pain, the more acute character of the febrile re- 
action, as marked by the pulse, skin, and thirst, and the kind of expecto- 
ration, when there is an}- , will always enable us to distinguish the two 
with almost absolute certainty. In cases, however, in which the two are 
combined, the diagnosis is not so easy, but even here the presence of 
dulness on percussion, and of crepitant or fine subcrepitant rale, or, when 
these are absent, of pure metallic bronchial respiration with bronchoph- 
on} T , over limited portions of the lung, will generally render the matter 
clear. 

The sudden supervention of dulness on percussion over large portions 
of one of the lobes of a lung, or over disseminated patches, with feeble or 
absent respiratory sound, or with muffled and distant bronchial respira- 
tion, generally indicates the occurrence of collapse in the part of the lung 
over which these signs exist ; and when these s} T mptoms show themselves 
without any increase in the severity of the febrile reaction, but rather 
with a diminution, there is every reason to suppose that they depend, 
not upon inflammatoiy condensation of the parenchyma of the lung, but 
upon simple collapse, from the presence of obstructive secretions in the 
bronchia. 

Dr. Gairdner (loc. czY., p. 6) has called attention to a difference in the 



PROGNOSIS. 203 

character of the dyspnoea in the two diseases, which is, we think, of con- 
siderable importance, and which we have often remarked ourselves. In 
bronchitis, of any considerable severity, the respiration is always evi- 
dently laborious ; it is performed only with the aid of all the accessory 
muscles of respiration, and in realty severe cases it is laborious, the in- 
spiration being long-drawn, exhausting, and inadequate. The dyspnoea 
of pure pneumonia is, on the other hand, quite different. It is merely 
an *• acceleration of the respiration, without any of the heaving or strain- 
ing inspiration observed in bronchitis, or in cases where the two diseases 
are combined." Dr. Gairdner states that he has repeatedly seen patients 
affected with a great extent of pneumonia of both lungs, in whom the 
extreme lividity and rapid respiration, numbering fifty or sixty in the 
minute, showed, infallibly, the amount to which the function of the lung 
was interfered with, who, nevertheless, lay quietly in bed, breathing with- 
out any of the violent effort, or disposition to assume the erect posture, 
so constantly accoropairring the more dangerous forms of bronchitis. In 
children these differences are even more marked than in adults. 

Chronic bronchitis may be mistaken for tuberculosis of the lungs or of 
the bronchial glands. The distinction can be made only by careful study 
of the histoiy of the case, and of the phenomena afforded by auscultation 
and percussion, which are detailed in our article on tuberculosis. 

Prognosis. — Bronchitis is rarely a fatal disease, so long as it remains 
confined to the larger bronchia, constituting the acute simple form, of 
moderate severity. Capillary bronchitis is, on the contrary, a very dan- 
gerous affection at all times and at all ages. Even ordinary, simple bron- 
chitis, however, may prove fatal in young infants, and in debilitated 
children of all ages, from the supervention of collapse of portions of the 
pulmonary tissue ; and it is necessary, therefore, that the prognosis given 
should always be guarded, when the disease occurs under either of these 
two conditions. The prognosis differs also in the primary and second- 
ary forms of the disease, since, as might be expected, the danger is much 
greater in the latter than in the former variety. 

We have met with a large number of cases of bronchitis, out of which 
we have kept more or less copious notes of 123. Of these, 108 were mild, 
and 15 capillary. Of the 108 mild cases, 65 were primary, all of which 
recovered; and 43 secondary, of which 2 died. Of the 15 capillary cases, 
11 were primary, of which one died, and 4 secondary, of which 2 died. 
Of the whole number, 123 in all, 5 proved fatal. The danger from the 
disease depends very much also upon the hygienic conditions in which 
the patients are placed. In hospitals and amongst the poor it is much 
more dangerous than in private practice amongst the easy classes of so- 
ciety. This is shown by the fact that all the cases of the capillary form 
observed by MM. Killiet and Barthez, and Fauvel, in hospital practice, 
proved fatal, while of 15 cases seen by ourselves, in private practice, 
under the most favorable hygienic conditions, only 3 died. 

The s3 r mptoms indicating great danger are, increase of the dyspnoea, 
extreme anxiety, small and irregular pulse, coolness or coldness of the 
skin, with clammy sweats, much jactitation, and delirium, drowsiness, or 



204 BRONCHITIS. 

coma. "With such symptoms the danger is greater and the fatal termi- 
nation more imminent in proportion as the child is younger, less robust, 
and its constitution exhausted b}^ preceding or coincident disease. 

Treatment. — The acute simple form of bronchitis is frequently so mild 
as to need no other treatment than careful attention to the Irygienic con- 
dition of the patient, and the administration of some simple febrifuge 
and expectorant. The child ought to be confined to one room, in a mild 
and uniform temperature, and should be kept quiet until the development 
of the s3 T mptoms shows what is to be the type of the attack. The degree 
of repose of the bod}- necessary will depend on the presence or absence 
of fever. We believe that the practice of keeping the body quiet in all 
febrile disorders, is one of the most important therapeutic means we have. 
It is long since one of us, having seen his father insist upon putting chil- 
dren to bed for a feverish cold, began to follow the same practice. Time 
and experience have made even more clear to us the wisdom of the prac- 
tice, especially in regard to very j^oung children. 

So soon as the attack of bronchitis becomes severe enough to cause 
fever, whether the fever be continuous or occur only in the afternoon and 
night, the patient ought to be confined to the lap or bed. Suckling chil- 
dren, and those under three years of age, must be allowed to lie on the lap 
at times, but even they may be taught, very early, to rest quietly in the 
crib the greater part of the twenty-four hours. Children over three years 
old can almost alwaj^s be taught to stay in their beds by a little manage- 
ment and authority, if only the parent is resolute. If not very sick, they 
should have a large pillow put up against the head of the crib or bed, and 
against this they should be placed in a sitting posture, with the bed- 
clothes arranged over the lap ; and, in cool or cold weather, with a light 
flannel sack over the night-dress. Here they ought to be kept all da}^ 
allowed to change their positions as. they wish, and they should be kept 
as cheerful and happy as possible with toys, books, pictures, readings, 
tale-telling, or what not. Under such circumstances, a new and interest- 
ing toy will often do more good by far than any drug in the materia 
medica. We have often been surprised, and delighted, too, to find a 
bronchitis which had been hanging over a 3'oung child for several days 
or a week, getting gradually worse, day by day, under the trotting-about 
system, begin to mend from the day the child was put to bed, and dis- 
appear in two or three days, and that, too, without any change in the 
other remedies. 

The clothing ought to be warm, and yet not sufficient to produce free 
perspiration, as this, by sudden exposure and evaporation, often induces 
chilliness. The diet must be simple, and may consist of any of the milk 
preparations, with or without bread, or bread and butter. Light soups 
in the middle of the daj T , or roast potatoes or apples, with bread, may 
general^ be allowed. 

As for medicines, in this mild form they are of comparatively little con- 
sequence, if the above measures be carried out. In the after-part of the 
day, when fever sets in, we may prescribe a febrifuge of citrate of potash, 
such as the following, for children of two to four years old : 



TREATMENT. 205 

R.— Potass. Citrat., gj. 

Syrap. Ipecac, fgj vel gij. 

Tr. Opii Camph., f^j vel gij. 

Syrup. Simp., f^ss. 

Aqua?, ad f^iij. — M. 

A teaspoonful every two or three hours. 

This should be given until the child sleeps, and occasionally in the 
night if there be cough and restlessness. At six months of age, the fol- 
lowing may be used in the same manner : 

R. — Syrup. Ipecac., 

Tr. Opii Camph., aa . . fgss. 

Spts. iEther. Nitros., vel 

Liq. Amnion. Acetat, .... f^ij. 
Syrup. Simp., ..... fgv. 

Aqua?, fgij. — M. 

Give a teaspoonful every two hours. 

If the fever is very slight, and the cough only moderately severe, it is 
often well to use no drug through the da}^, but to give in the evening, two 
hours before bedtime, and again at bedtime, some simple expectorant 
and anodj'ne. Thus at two or three months of age, three to five drops of 
syrup of ipecacuanha with five of paregoric, or half a drop to a drop of 
laudanum ; at one or two years, ten drops of the syrup with ten to twenty 
of paregoric, or two of laudanum ; at five to ten 3 r ears, ten to twenty 
drops of the syrup, with twenty to thirty of paregoric or five of lauda- 
num. The laudanum is often better than paregoric, as it produces a more 
decided and lasting impression on the nervous system, and appears to ex- 
tend its useful control over the sj-mptoms further into the following day. 

In this very mild form there is no necessity for giving active purga- 
tives. If the bowels are moved once in the day, or once in two da}'S, it 
is best not to interfere with them. If, however, the patient be consti- 
pated, a little simple syrup of rhubarb, a teaspoonful of castor oil, or an 
enema, will be quite sufficient. A warm foot-bath, containing salt, or, 
better, mustard, in the evening, will often assist in moderating the cough 
and promoting quiet sleep. 

When, in this acute form, the symptoms assume greater severity, when 
signs of reaction are prominent, the dyspnoea considerable, and the cough 
frequent and harassing, it was formerly quite the custom to employ de- 
pletion. In the last edition of this work, it was stated that the abstrac- 
tion of a few ounces of blood by leeching or cupping, was allowable under 
these circumstances, but that a large majority of such cases would do 
perfectly well without bloodletting of any kind. We now believe that 
such practice is unnecessary in any of this class of cases. Attention to 
hygienic measures is, howeA 7 er, even more important than in the milder 
cases. Confinement to the bed ought to be a positive rule in such cases. 
If the bowels are not freely moved, a dose of castor oil, rhubarb, or mag- 
nesia should be given, and the patient then put upon the use of one of 
the febrifuge mixtures recommended above. When the fever is very 



206 BRONCHITIS. 

high, and the patient over a year old, antimonial wine may be substi- 
tuted, with advantage, for the syrup of ipecacuanha. 

If, as the case progresses, the bronchial secretions become very abund- 
ant and the dyspnoea severe, the proper remedy is an emetic. This may 
be ipecacuanha, either in powder or syrup, or a teaspoonful of powdered 
alum, to be repeated if necessaiy, in ten or fifteen minutes. The latter 
substance is, as we have stated under the head of croup, a very certain, 
efficient, and safe emetic. 

Great benefit may be obtained in all forms of bronchitis, from the more 
or less frequent application of mustard poultices to the front or back of 
the thorax, and from mustard foot-baths. 

The mercurial preparations, so much recommended by many of the 
English and b}^ some of our own writers, are, in our opinion, very seldom, 
if ever, necessaiy in this, or indeed, in any of the forms of bronchitis in 
children. 

MM. Itilliet and Barthez recommend, when the cough and sibilant rale 
persist after the disappearance of the febrile sj 7 mptoms, the use of small 
doses of the flowers of sulphur. We have ourselves known this remedy 
to prove of service in such cases. About four grains may be given every 
three hours to a child four years old. 

The treatment of the grave acute or capillary form of this disease brings 
up again the question of bloodletting. We, like all the rest of the world, 
have abandoned the practice as a rule, but we think that when, in a case 
of the kind now under consideration, the age being over two } T ears, the 
oppression is very great, the right heart laboring, as shown by a congested 
surface and a throbbing cardiac impulse at the base and left edge of the 
sternum, and the strength not too much reduced, the abstraction of from 
two to four ounces of blood from the interscapular space hy cups or 
leeches, would be a useful and legitimate practice. We venture to give 
this advice from our own past experience, and from the views taught quite 
lately as to the effect and value of depletion in relieving the over-distended 
right heart, produced by an obstacle to the pulmonic circulation. 

There is no occasion for repeating here what has been said, under 
the head of pneumonia, in regard to tartar emetic. But if the tempera- 
ture be very high, and the pulse full and strong, we believe that the small 
doses of sulphurated antimony (gr. T ^) we then recommended, in combi- 
nation with Dover's powder, every two or three hours, are very useful in 
moderating the inflammatoiy symptoms. Should this be followed by 
nausea or vomiting with exhaustion, ikey must be suspended at once. The 
physician, and especially the 3 T oung and inexperienced, ought to know that 
the susceptibility to the action of all antimonials is singularly different in 
different individuals. We have seen a hearty adult woman thrown into a 
most violent, and for a time alarming choleraic condition, bj^two doses of 
yLth of a grain of tartar emetic each. We saw once a fine hearty boy five 
years of age, vomit violently, grow pale, weak, and faint away, from two 
teaspoonfuls of the mel. sciHae compositum, containing in the two doses, 
the fourth of a grain of tartar emetic. And even twelfths of a grain of the 
sulphurated antimony will sometimes cause a degree of nausea and pros- 



TREATMENT. 207 

tration in young children which ought not to be kept up, though we never 
saw it occasion such effects as those just mentioned as following the use of 
tartar emetic. When, therefore, the sulphurated antimony acts with any 
undue violence, it ought to be stopped, and we should substitute the citrate 
of potash mixture proposed for the mild form of bronchitis. 

In connection with one of these internal remedies, counter-irritation to 
the surface of the chest will be found of very great service. Indeed, we 
doubt very much whether it is not the most important part of the treatment. 
It may be obtained by applications of dry cups to the back of the chest, 
or if this be inconvenient or objected to for any cause, by the use of mustard 
poultices. The poultice ought to be about the size of the hand, or one-half 
larger, and it should be made of one part mustard to two of Indian meal or 
flour. It is to be mixed with warm water, covered with book muslin or cam- 
bric, and applied first to the dorsum of the chest ; after having reddened at 
that point, it should be shifted to the front of the thorax. The time nec- 
essary for each contact is usually from ten to fifteen or twenty minutes. 
These applications ought to be renewed once in four hours, when the 
symptoms are only severe, but when these are urgent, they should be 
made every two hours. We are in the habit of depending very much, 
also, on mustard foot-baths. When the oppression is severe, anc] espe- 
cially where there is any coolness of the extremities, the use of a foot-bath 
simultaneously with the mustard poultice, will often assist very much in 
relieving the breathing-. 

In very young infants, antimony ought not to be employed, in my 
opinion, and in these, therefore, we need some other remedy. In them 
ipecacuanha is much safer than antimony, and it is quite active enough. 
The best preparation is the syrup, of which from three to five drops may 
be given every two hours to infants six months old. In older children, 
also, in whom we have been obliged to suspend the antimony, and in 
those in whom its use has been contraindicated by delicacy of constitu- 
tion or by feeble health, the ipecacuanha is preferable. The doses must 
vary with the age. At five years, about ten drops every two hours, in 
combination with the same quantity of spirit of nitrous ether, is a proper 
dose. When the child presents a pale surface and a languid expression, 
and particularly when the skin is very slightly warmer than usual, or 
coolish, the following prescription has proved a most useful one in our 
hands : 

R. — Liq. Ammon. Acetat., .... f jfss. 

Syrup. Ipecac, f gj. 

Liq. Morph. Sulphat., gtt. xl. 

Syrup. Acaciaa, f 5J. 

Aquse, f^jss. — M. 

Ft. mistura. 



The dose of this is a teaspoonful for a child two years old, to be re- 
peated every two hours. Should there be any nausea present, the syrup 
of ipecacuanha ought to be reduced to half the quantity ; and if there be 
any drowsiness, the morphia must be left out. 



208 BRONCHITIS. 

In very severe cases of the disease, in which the dyspnoea is excessive, 
the pulse rapid and small, the skin cool and pale, the jactitation very 
great, and when there is present extensive mucous and subcrepitant rale, 
the treatment generally recommended is the frequent employment of 
emetics, and the French authors usually prefer tartar emetic. For our 
own part, we would not venture to administer, under such circumstances, 
so powerful a remedy, and especially so potent a sedative, as antimonj?-, 
one that we have so often known to cause alarming and dangerous pros- 
tration in children laboring under much slighter disorders than suffoca- 
tive bronchitis. If any emetic be given, it ought to be one of milder 
action and less perturbing influence than tartar emetic, and we should 
choose, therefore, either ipecacuanha or alum. The plan of treatment we 
prefer, however, is to make assiduous use of counter-irritants, and to 
give internally the spirits of Mindererus and a weak decoction of seneka. 
Depletion is, in these cases, either entirely contraindicated, or it should 
be resorted to only by the application of two or three small scarified cups. 
In a very severe case of this kind, the dangerous symptoms subsided 
under the use of cupping, mustard poultices and foot-baths frequently 
renewed, and the internal use of decoction of seneka and spiritus Minde- 
reri ev^ry hour. Six small cups, of which only two were scarified, were 
applied once over the back of the thorax. In another case, which occurred 
in a child eighteen months old, during an attack of measles, the symptoms 
yielded and the eruption made its appearance, under the use of mustard 
foot-baths and poultices applied every two hours, and the internal use of 
spiritus Mindereri and spirit of nitrous ether. In both cases the symptoms 
of exhaustion were so strongly marked, that we feared to employ emetics, 
lest they might fatally increase the alreadj- dangerous prostration, though 
the dyspnoea and abundant mucous and subcrepitant rales seemed to call 
for them. 

In the bronchitis of children, it often becomes proper and necessary to 
make use of stimulants. In the suffocative form, when the symptoms 
assume the character described in the last paragraph, small doses of 
brand} T or wine-whey may be administered alternately with the spirits of 
Mindererus, with great advantage. In milder cases, also, when a sudden 
increase of the dyspnoea occurs, especially in feeble and debilitated sub- 
jects, and when we may suppose, from the character of the rational and 
physical signs, that collapse of portions of the lung has taken place, it is 
best to abandon for the time all nauseating remedies, and to make use 
simply of brandy in closes of from five to twenty drops every half hour 
or hour, or of wine-whey in dessert or tablespoonful doses, and of coun- 
ter-irritants, with very light fluid nourishment. 

In cases where there is such marked debility, tonics are very useful, 
and good results may be obtained from the administration of quinia, 
which was strongly recommended a few years ago, in the form of capillary 
bronchitis occurring in tropical climates, by Dr. Cameron (London Lan- 
cet, November 9th, 1861). 

In cases of this kind, we have used with great advantage of late years 
small doses of quinia, prepared as follows : 



TREATMENT. 209 

R. — Quinine Sulphat., gr. vj. 

Acid. Sulph. Dil., gtt. xij. 

Syrup. Sirup., f^ss. 

Aquae, f^ijss. — M. 

Give a teaspoonful every two hours, to children two or three years old. 

In older children the proportion of qninia to the dose ought to be 
doubled. If this should sicken, as it will sometimes do by the dis- 
gust its bitterness produces,, and the consequent resistance to the doses, 
it is best to lav it aside after two or three trials, and substitute the fol- 
lowing: 

R.— Elix. Cinchon. Flav., f gij. 

Curacoa, ....... f^ij. 

Acid Sulph. Dil., mxij. 

Aquae, f ^ijss. — M. 

Dose, a teaspoonful every two hours. 

The child ought to be laid on an inclined plane of pillows, and, with 
the exception of turning it gently towards one side or the other, from 
time to time, it should be kept perfectly quiet. These directions are 
particularly important in very young children, as it is in them that de- 
bility and exhaustion of the muscular forces are apt to bring about the 
state of collapse just referred to. 

As an example of the kind of case in which stimulants are useful, and 
to show also the dangerous effects which antimony sometimes produces, 
we will quote the following : A girl between seven and eight years old, 
was attacked while in good health with severe bronchitis. On the second 
day, when we were called, she was very much oppressed, the skin was 
hot and dry, the pulse rapid, and the surface pale. We ordered a cup- 
ping to the amount of four ounces, with some dry cups besides, over the 
back, and two drops of antimonial wine with ten drops of sweet spirits 
of nitre to be given every two hours. On the third day a blister was 
applied over the sternum. On the fourth day we found the child in 
the afternoon very pale, dozing or tossing about on the bed, and some- 
times rising up on her hands and knees with a bewildered look ; she was 
inattentive, so that it was almost impossible to catch her eye ; the eyes 
were sunken, and the countenance was distressed and anxious ; she 
moaned constantly and looked very ill ; the skin was still hot ; there was 
neither vomiting nor purging. The respiration was very much oppressed, 
and she coughed a good deal, though not so much as before. We sus- 
pended the antimony at once, and gave a teaspoonful of brandy in water, 
directing it to be repeated in three-quarters of an hour ; after the second 
dose a teaspoonful was to be given in a wineglassful of milk and water 
every two hours throughout the night. On the following morning, the 
child looked better ; she was less pale, and the e t yes were not so excavated. 
The breathing was better. She was still very drowsy, but often waked 
partially w T ith screaming and affright, and when awake took very Little 
notice. The milk and brandy were continued every two hours. On the 

14 



210 BRONCHITIS. 

afternoon of this day, all the unpleasant sjmiptoms had disappeared ; 
there remained only those indicative of a slight bronchitis, and she was 
soon quite well. Now it seems to us exceedingly clear that, had the 
antimony been continued in this case, on account of the hot, dry skin, 
oppressed breathing, frequent cough, and from the absence of vomiting 
or purging, the child would have died. 

The most important points in the treatment of chronic cases, are to 
insist upon a rigorous and persevering regulation of the hygienic con- 
ditions of the patient, and to make use of tonic, balsamic, and expector- 
ant remedies. The child should be carefully and warmly clothed, and, 
when at home, kept in dry, well-ventilated, and, if possible, airy rooms, 
at a uniform temperature. The living room of such a child ought to be 
heated in winter by a wood-stove, or open wood-fire, if that is sufficient 
to keep up a proper temperature. In our cold winters we have found no 
plan so good as a well-managed wood-stove. Coal fires cannot be lowered 
or extinguished at night, as they ought to be, and often keep up, through 
the clay, too high a temperature. They are unmanageable. 

These, indeed, constitute the truly important part of the treatment, for 
without them, there is but little, chance that drugs of any or of all kinds, 
diet, or any other measures, will be of any real service. The dress and 
temperature ought to be the first things attended to, and after them, and 
as a secondary matter, certain medical substances will assist in removing 
the disease. The child ought to be taken as often as possible into the 
air in fine weather, and only in fine weather. The diet should be selected 
with a strict view to the improvement of the strength and vigor of the 
constitution ; the food may consist, if the child be of proper age, of light 
meats, of potatoes and rice, as the only vegetables, and unless there is 
some contraindicating circumstance, of a small quantity of wine with the 
midday meal. The best wine is port, of which one or two tablespoonfuls 
ma} r be given in a considerable quantity of water. 

Tonics must be administered throughout the course of the disease, or 
until the appetite and strength shall have improved to such an extent as 
to make them no longer necessary. The best are quinine, in the dose 
of a grain morning and evening, to be continued for several weeks ; or, 
when the child is thin and anaemic, small doses of arsenic with iron, as 
recommended in the article on eczema, and cod-liver oil, in doses of half 
a teaspoonful to a teaspoon fill, three times a day after meals, either pure 
or in some carefully-made emulsion, will often greatly assist in curing 
these chronic forms of catarrh. 

In one case of chronic bronchitis, which came under our care, the pa- 
tient recovered under careful regulation of the hygiene, and the use of a 
decoction of seneka, prepared by boiling a drachm, each, of seneka and 
liquorice roots, in a pint of water, to half a pint. The decoction was 
strained, and a large teaspoonful given three times a day. The reined}'' 
was continued during a period of two months ; under its use the child 
grew fat and strong, and recovered entirely from the disease. 

Other remedies, proposed b} r different authors, are the various resin- 
ous preparations, the balsams of tolu and copaiba, benzoin, and the sul- 



PLEURISY. 211 

phurous mineral waters. In cases of long-standing, where mucous rales 
persist throughout the lower part of the lungs, showing an abundant 
morbid secretion, tannic acid has been found, b} r several good authorities, 
of much service. "While these means are employed, it is recommended, 
also, to make use of counter-irritants. If any are used, they ought to be 
such as will not produce too much inflammation of the skin; as, for in- 
stance, weak Burgundy pitch plasters, daily frictions with hartshorn and 
sweet oil, a simple diachylon plaster, or very mild pustulation with cro- 
ton oil. 



AETICLE IV. 

PLEURISY. 

Definition; Frequency; Forms. — Pleurisy consists in inflammation 
of the pleural serous membrane. 

Idiopathic pleurisy is a rare disease under five years of age, and espe- 
cially in the first and second years of life. After the age of five years it 
becomes more frequent. We have met with 28 cases of pleurisy, of which 
we have kept notes. Of the 28, 26 were idiopathic, and 2 secondary; one 
of the latter occurring during hooping-cough, and the other being accom- 
panied by pneumonia, though the pleurisy was the predominant disease. 
Secondar} 7 pleurisy, on the contrary, or that which occurs in the course 
of other diseases, is common at all ages. M. Bouchut met with it in 23 
out of 68 autopsies of new-born and suckling children. Of the 23, 9 ac- 
companied acute pneumonia, 6 tubercular pneumonia, 5 entero-colitis, and 

3 different other diseases. This form of the affection is rarely detected 
during life, being masked by the concomitant malady. 

We shall describe two forms of the disease, the acute and chronic 
Predisposing Causes. — As to the influence of age r it has already been 
stated that idiopathic pleuris} 7 is rare between birth and five years of age. 
It is certainly rare, during those years, in comparison with pneumonia^ 
and especially with bronchitis, for we find that while we have met with 
but 15 cases of pleurisy of all kinds under five years of age, we have seen 
28 of pneumonia under that age, and 105 of bronchitis under 6 years of 
age. Of 28 cases of pleurisy that we have seen, 26 were idiopathic, and 
of these one occurred at the age of three months ;. three between 1 and 2 
years of age ; one between 2 and 3 ; four between 3 and 4 ; eight between 

4 and 5 ; three between 5 and 6 ; two between 6 and. 1 ; three be^veeii 7 
and 8 ; and one between 13 and 14. Of the two secondaiy cases, one oc- 
curred at six weeks of age, and one between 4 and 5 years. Secondary 
pleurisy is said, by the best authorities, to be most frequent between one 
and five years of age, being, in this respect, just the contrary of the idio- 
pathic form of the disease. 

Pleurisy is said to occur more frequently in boys than girls. Of 26 
cases, in which we noted the sex, 19 occurred in boys and T in girls. 



212 PLEURISY. 

The idiopathic form is most apt to occur in vigorous and hearty subjects, 
while the chronic and cachectic forms attack those who are feeble and 
delicate. It is often, as already stated, a secondary affection, occurring 
particularly during pneumonia, and, after that disease, during rheuma- 
tism, scarlet fever, and B right's disease. Season is another predisposing 
cause. It is most common during winter and spring, especially the latter. 

The exciting causes are very obscure in most cases. The only ones 
which seem to have been ascertained with any certainty, are exposure to 
cold and sudden changes of weather. It has been said to follow external 
violence. In one of the cases that came under our, own observation, the 
child had struck the affected side severely against a pointed stick on the 
day of the attack. 

Anatomical Lesions. — The serous membrane may retain its natural 
characters, which happens in the majority of cases, or it may present the 
different appearances indicative of inflammation. These are more or less 
minute and abundant injection and punctuation, and spots or patches of 
an ecchymotic appearance, observable particularly at the points where the 
formation of false membrane has taken place. Another change produced 
in the pleura by inflammation is the loss of its natural polish, which is 
replaced by a more or less granular and rough appearance. In chronic 
cases it becomes whitish or opaline in color, and thickened. It is very 
rarely softened. 

In addition to the lesions of the pleura itself there are various diseased 
products of secretion which require notice. These maybe either solid or 
liquid. The solid products are the false membranes which exist so gen- 
erally in all serous inflammations. They are found both upon the costal 
and pulmonic pleura. In their recent state they are of variable size and 
thickness, being in some cases very soft and deposited in small points ; 
in others, more extensive, but thin, like paper; and in others again thicker 
(one or two lines in thickness), firmer, and decomposable into several 
layers. The outer layers are yellow, elastic, and soft, while the inner 
ones are red, more resisting, and marked with vascular arborization. 
When examined some time after their formation, the false membranes 
are found to have been converted into cellular adhesions, which may be 
either very loose, or they may fasten the lung tightly to the costal pleura. 
The adhesions are generally, however, thin, transparent, and in the form 
of loose bridles. After a length of time, the false membranes, come to 
present the appearances of true serous tissue, and like that, are suscepti- 
ble of inflammation. 

The fluid found in the pleural cavity usually consists of transparent or 
turbid serum, holding albuminous flocculi in suspension. Sometimes, but 
more rarely, it consists of purulent serum, and still more rarely of pure 
pus. The liquid generally occupies the lowest portion of the thoracic 
cavity, but is sometimes circumscribed at various heights, or between the 
lobes of the lung, by abnormal adhesions, or by some part of the lung 
which has been rendered incompressible by inflammation. 

The lung presents various alterations from its healthy condition. It is 
pressed backwards towards its root to a greater or less extent. The 



PHYSICAL SIGNS. 213 

tissue of the organ is generally found in one of two conditions : either 
hard, not crepitating, impenetrable to the finger, and presenting a smooth 
surface when cut into, a state of things which has been expressed by the 
term camincation, and which is a mechanical effect of pressure ; or else 
the lower lobe, which is in contact with the fluid, is large, heav}^ fleshy, 
rather hard, not so easily penetrable by the finger as in simple hepatiza- 
tion, yielding under pressure only a small quantity of blood, and but 
slightly retracted towards the spinal column. The latter condition de- 
pends in all probability on an effusion which has occurred after, or coin- 
cidentally with, hepatization. 

In some cases, in which the effusion is but small, or where it has been 
absorbed, the lung is found to be elastic and crepitating. Whatever the 
amount of erfusion may be, it is said that the lung can always expand to 
its normal size if the fluid be absorbed, unless it has been too firmly 
bound down by false adhesions. 

Pleuris3 T , whether complicated with pulmonic disease -or not, is much 
the most frequently confined to oue side. In idiopathic cases, it is more 
common on the right than left side ; wdien it accompanies pneumonia, it 
is, on the contrary, more common on the left than right. 

Symptoms. — In describing the sjmiptoms, we shall treat first of the 
physical, and then of the rational signs, and of the course of the disease. 

The physical signs are exceedingly important, as they often constitute, 
especially in young children, the only means of recognizing the disease. 
The pleural friction-sound is less important than some other physical 
signs, as it is scarcely ever heard in children under five years of age, and 
only during the absorption of the fluid, as a general rule, in those above 
that age. Bronchial respiration may commonly be detected from an 
early period in the attack. At first it is heard during inspiration, but 
afterwards it exists both during inspiration and expiration, or in the 
former alone. In a majority of the cases it is heard over the posterior 
portion of the thorax, and upon one side only. At first it is audible over 
nearly the whole height of the affected side, while later in the disease, it 
can be perceived only at the inferior angle of the scapula or in the inter- 
scapular space. Its duration is variable; it may disappear in a few days, 
or last for a much longer time. In favorable cases it is usually replaced 
by feeble vesicular respiration, more rarely by friction-sound, and some- 
times by pure respiration. This sign is almost always present at all ages 
in acute cases, but is often absent in those which are slow and tedious. 
In suckling children it is not constant, but intermits occasionally , so that 
it maybe heard at one and not at the next examination. JEgophony can 
rarely be detected in children less than two years old. Under that age, 
there is heard instead of it resonance of the cry, especially in the region 
beneath and on a line with the spine of the scapula. It is intermitting 
like the bronchial respiration. In children over two 3-ears old, eegophony 
can often be distinguished by careful examination, but never, of course, 
unless the quantity of effusion is considerable. It is heard at an early 
period of the attack, and chiefly in acute cases, and must be sought for 
in the low T er portion of the interscapular space, and the inferior dorsal 



214 PLEURISY. 

region. It coexists almost invariably with bronchial respiration, lasts 
bnt a short time, disappearing after one, two, three, or four days, and it is 
intermitting. In older children, it is sometimes replaced by diffused reso- 
nance of the voice, as it is by resonance of the cry in infants. In a case 
that occurred to one of ourselves, in a girl between six and seven years 
old, and in which the disease became chronic, the voice was not purely 
segophonic, but reedy and quavering, from the fifth to the tenth clay. After 
that date the effusion became so great that all sound was suppressed. 

Feebleness or absence of the respiratory murmur seldom exists at the 
beginning of acute cases, but in the subacute or chronic form is generally 
present from the invasion. In the latter class of cases feeble respiration 
is noticed first over the inferior portion of the dorsal region, but, as the 
effusion increases, it is heard also in the upper and anterior regions, and 
becomes more and more feeble, until at length no sound whatever is audi- 
ble ; the respiratory murmur is suppressed. In acute cases, on the con- 
traiy, the absence of the respiratory sound is observed at variable periods 
of the attack ; when noticed soon after the invasion, it is generally coin- 
cident with bronchial respiration, which, heard at first over the whole or 
the inferior three-fourths of the dorsal region, becomes afterwards percep- 
tible only in the interscapular space, or at the inferior angle of the scapula, 
while the respiration is feeble or absent over the lower portions of the 
lung. In acute cases the feeble respiration remains limited to the dorsal 
region, and disappears after a few days, — in from five to eight, according 
to our experience ; while in chronic cases it extends over a larger surface, 
and continues for several weeks, or even months. 

Percussion. — This means of diagnosis is very important in all cases of 
the disease accompanied by effusion of liquid, unless the quantity be ex- 
ceeding^ small. When, on the contrary, the inflammation results merely 
in the production of thin false membranes, percussion furnishes no useful 
information. 

Percussion is of no assistance, however, at the moment of invasion, as 
it is not until the period at which effusion takes place that the resonance 
of the thorax begins to be altered. In acute cases, the resonance is gen- 
erally duller than natural, though seldom entirely dull, on the second, 
third, or fourth day. As the effusion augments, the dulness increases 
over the region occupied by the fluid, until at length all resonance ceases, 
and the sound is perfectly fiat. The degree of dulness can be property 
appreciated onty by comparing the two sides together. The degree, ex- 
tent, and duration of this sign will depend, of course, upon that of the 
effusion. In children, as in adults, the sounds afforded by percussion 
vary with the position of the patient, which influences, of course, the 
situation of the fluid in the pleural cavity. 

In regard to the physical signs of pleuro-pneumonia, it may be stated 
that when a pleuritic effusion takes place in a child laboring under pneu- 
monia, it happens, as a general rule, that the bronchial respiration occa- 
sioned by the inflammation of the lung increases in intensity, though in 
some few cases it is diminished or suppressed. MM. Rilliet and Barthez 
krv down the following principle: "That iclien a pleuritic effusion occurs 



RATIONAL SYMPTOMS. 215 

in a child affected with hepatization of the inferior portion of the lung, 
all the abnormal sounds which were perceptible over the diseased point 
are considerably exaggerated, and the sonority disappears.' 1 ' 1 

Inspection of the thorax affords no assistance at the invasion of the dis- 
ease, nor generally in acute cases which last but a short time, and in 
which the amount of effusion is small. When, however, the effusion is 
large, it may be observed, upon close examination, that the movements 
of the affected side during respiration are more limited than those of the 
opposite one, and that the intercostal spaces are more projecting than 
natural, in consequence of distension by the fluid within. At the same 
time mensuration will show that the side on which the effusion exists is 
larger than the other. The difference may amount to one-third or two- 
thirds of an inch. In acute cases, in which the quantity of liquid is 
small, mensuration will of course show no difference. 

Palpation is an important means of diagnosis, especially in making 
the distinction between pneumonia and pleurisy. In the former disease, 
the vibration of the thoracic walls during either crying or speaking, is 
augmented ; whilst in the latter it is diminished, or when the effusion is 
considerable, ceases altogether. This sign is important, both in infants 
and older children. 

Rational Sy3iptoms ; Course ; Duration. — Acute pleurisy is rarely 
met with, as already stated, in children under six years of age, except as 
a secondary affection. In idiopathic cases it begins with severe pain in 
the side, cough, some difficulty of respiration, increased frequency of the 
pulse, loss of appetite, thirst, bilious vomiting, sometimes headache, and 
in rare instances delirium. The pain in the side or stitch is almost always 
present in acute cases occurring in healthy children, while in those which 
are slight, or which occur in weak and debilitated subjects, or very young 
children, it very often cannot be detected. Sometimes, however, its ex- 
istence maj r be ascertained in very young children by tenderness of the 
side shown during the act of percussion. When present in young chil- 
dren, it can always be detected by watching the face of the child and ob- 
serving its gestures during the act of coughing, and during full inspira- 
tions, as in those made in crying, after sudden movement, or in the act 
of gaping. In an infant of thirteen months old, who was attacked with 
pleurisy of the right side, causing effusion of thick yellow pus into the right 
pleural sac, and which ended fatally in a month, only the blindest observer 
could fail to see that every act of coughing was acutely painful, for the 
child uttered each time a short, sudden cry, which was hushed as soon as 
given, while at the same moment there passed across the face an expres- 
sion, amounting almost to a grimace, of suffering, which was unmistak- 
able. The pain is aggravated by coughing, by full inspirations, by change 
of position, and by percussion. The seat of pain is almost always in 
front, but it may extend irregularly over the whole of one side to the 
arm, or it may be confined to the false ribs, or less frequently to the 
neighborhood of the nipple ; it generally lasts from three to six days, 
though it sometimes continues longer. This symptom was complained 
of in most of the cases that we have seen. In some it was very acute and 



216 PLEURISY. 

severe for one or two claj^s, while in others it was slight, not well defined, 
and very transitory. In one, the child said there was no pain, but a sen- 
sation of weakness in the side when she coughed. In another, the pain 
was severe for a few hours, but was relieved b} T a sinapism, and was not 
felt again, though the attack resulted in a very large effusion into the 
side. In a third it lasted a week, and in a fourth only two da3 T s, though 
in both the effusion was extensive, and required several weeks for its ab- 
sorption. In a fifth case it continued for five days. In the last, the effu- 
sion was very slight. It was aggravated in all these cases by coughing, 
by the act of respiration, especially when this was deep, and by motion. 

Cough exists in nearly all idiopathic cases, and generally from the 
onset, though sometimes not before the second or third day. Usually 
frequent and dry, it commonly retains these characters in acute cases, 
for four or six days, and then diminishes rapidly. In more tedious cases 
it continues for a longer time, but moderates in violence after some days. 
In secondary cases it has no special characters. It was present in all but 
one of the cases seen by ourselves. Its character varied very much. In 
some it was frequent, teasing, and very painful. In others it was rare, 
scarcely troublesome, and only slightly painful. In all it was very dry, 
this constituting one of its most marked features, and giving it a very 
different character from the cough of bronchitis, and also, though some- 
what less distinctively, from that of pneumonia. It continued almost 
entirety dry throughout the disease, except in a case which became com- 
plicated after a time with slight bronchial inflammation, and, in that, it 
became loose. There is generally no expectoration ; if any, it consists of 
a small amount of whitish, frothy, sero-mucous fluid. 

The respiration is usually accelerated in acute cases, but remains natu- 
ral in other respects ; the ctyspncea, however, is slight, as a general rule, 
compared with that of pneumonia. The difficulty of breathing is com- 
monly in proportion to the earliness of the age, and to the extent and 
rapidity with which the effusion takes place. In the acute cases that 
came under our own observation, the breathing was usually about 36, 38, 
40, and 48, but in one case it rose to 68 for a single day. It was not 
labored, and appeared to be difficult onty from the fact of its being more 
or less painful. In a case of double pleurisy that came under our obser- 
vation, it was most laborious, and dreadfully painful, as was also the 
cough. In the cases attended with but slight pain, there was no dysp- 
noea. It usually subsided after two or three days, when large effusion 
took place, converting the case into the chronic form. 

The fever is not usually very great, and seldom lasts more than a few 
da}-s, or a week. In some few cases, however, that we have seen, the 
febrile reaction has been very high. In one, in a child between three 
and four years old, the pulse rose to 172 on the first day, though the res- 
piration was but 36 ; the skin was very hot and dry, and there was very 
great drowsiness and inattention. In other cases the pulse was 140, 128, 
and 124. The acceleration of the pulse usually lasts three or four days, 
after which it falls, so that by the end of a week it is seldom over 70, 80, 
or 90. The heat of skin is not very great in most instances, and generally 



RATIONAL SYMPTOMS. 217 

subsides rapidly, and disappears after a few days. In acute secondary 
attacks, the febrile symptoms are more marked as a general rule, than 
as has just been described, because of the existence of the concurrent 
disease. 

The countenance presents no particular characters, except that an ex- 
pression of pain passes across it occasionally when the child coughs, or 
takes a deep breath. It is seldom deeply flushed as in pneumonia. The 
ala? nasi are dilated only during the continuance of the difficulty of res- 
piration. 

The decubitus is generally dorsal or indifferent. In two cases observed 
by us, in which the effusion was large, the number of inspirations was 
always from three to five greater when the child laid on the sound, than 
when on the affected side. 

Headache is often present during the first few days, in children over 
six years of age, and is sometimes very severe. 

Convulsions are said to occur sometimes at the onset in very young 
children. The strength is not usually much diminished, except during 
the acute period. The appetite is diminished and the thirst acute, but 
neither of these symptoms is so marked as in pneumonia. The tongue 
is usually moist, and sometimes covered with a coat of whitish fur; the 
abdomen is natural. 

Bilious vomiting is said to occur in more than half the cases. The 
stools are generally regular, or there is some constipation. 

Auscultation practised soon after the invasion generally reveals rude 
or bronchial respiration without any rhonchus. The percussion is dull. 
The cough, pain, fever, and difficulty of breathing continue for several 
days, after which all but the cough generally disappear, while that com- 
monly persists in a mild form. In acute cases, the appetite now begins 
to return, the thirst moderates, and auscultation reveals only feebleness of 
the respiratory murmur and slight dulness on percussion. The general 
symptoms cease soon after this, and the patient is entirely convalescent 
in from one to three weeks, though feeble respiration and diminished 
sonority sometimes persist for a longer period. 

Urine. — The urine in pleurisy has the so-called febrile characters, but 
usually not in airy degree approaching to the urine in pneumonia, the 
water being less diminished, and the urea less increased. In cases where 
there is rapid effusion into the pleura, the chlorides are lessened or almost 
wanting ; and reappear as the effusion is absorbed. Albumen is scarcely 
ever present. 

Chronic pleurisy may follow the acute form, or occur as an idiopathic 
disease. In the former case, the acute symptoms diminish after a variable 
length of time, but the fever does not cease entirety and often recurs to- 
wards eveniug. In the latter case there is usually a very moderate de- 
gree of fever at first, which soon subsides and then disappears, or there 
is none at all; the pain is generally, though not always, vague, uncertain, 
and attracts but little notice. In one case that we attended, the cough 
was frequent, rather dry, and very painful for the first few days, after 
which it became looser and ceased entirely, though the interior two-thirds 



218 CHRONIC PLEURISY. 

of the right side were filled with effusion for a period of two weeks after- 
wards. In a second, in which the whole of the left side was occupied by 
the effusion, there was no cough whatever. In a third, there was a very 
slight, infrequent cough during the first day, but after that, though the 
effusion occupied the right side up to the spine of the scapula, there was 
none through the da}', and merely a little hacking at night. In a fourth, 
in a girl, between four and five years old, there was considerable fever 
during the first week, but literally no local symptoms whatever, so that 
the case was mistaken for one of bilious fever by another physician. 
When it came under our notice, some obscurity in the sjmrptorus led us 
to examine the chest, where we found an effusion occupying the lower 
third of the right side. The fever was' now diminishing, and soon disap- 
peared, but the effusion increased, without pain, and with only an occa- 
sional cough, until it filled up three-fourths of the side. It then stopped, 
and after several daj's, began to recede. At the end of about six weeks, 
the child was quite well again, and continues so to this time, about three 
years. In a fifth case, in a boy, between five and six years old, the attack 
was extremely obscure. There was veiy slight fever, almost no cough, 
indeed none except upon some exertion being made, and then scarcely 
noticeable, and no severe pain whatever. In fact, the child complained 
of no pain whatever, but upon being asked, referred to an uneas}' sensa- 
tion in the inferior lateral region of one side. The tongue was coated, 
and the symptoms were rather those of some bilious derangement, than 
of anything more serious. It was not until after four or five days of at- 
tendance, that a careful examination of the chest showed the existence of 
a slight effusion in the right side. This gradually increased until it 
reached nearly up to the clavicle, and then slowly disappeared again. 
The respiration is somewhat accelerated in all cases, and when the effu- 
sion is very large, and especially when it is purulent and attended with 
violent hectic fever, it is sometimes excessively labored and difficult. In 
the cases that we have seen, however, even when the effusion has been 
very large, the breathing has not been difficult. In one case it was be- 
tween 40 and 50 during the first two days, after which it fell, as the effu- 
sion took place, to 30. In a second it was 45 at first ; at the end of a 
week it was 38 ; at the end of the third week, as the effusion was being 
absorbed, it had fallen to 28, soon after which the recovery was completed. 
In a third it was so slightly disturbed that we did not at first suspect any 
disease of the chest. On the fourteenth day. the effusion reaching then 
nearly to the spine of the scapula, the breathing varied between 40 and 
28 during sleep, but during the waking state there was no visible oppres- 
sion. 

The effusion takes place gradually, and is generally large. The per- 
cussion is now entirely dull over a greater or less extent of the side, and 
the respiratory sound is suppressed. The side is evidently enlarged, the 
increase of size being visible to the eye and ascertainable by measure- 
ment. If the effusion be purulent, constituting empyema, and the case 
is to end unfavorably, the child emaciates, grows pale, has night-sweats 
and hectic fever, and dies at last in a state of profound exhaustion. In 



DIAGNOSIS. 219 

favorable cases, on the contrary, and nearly all those in which the effusion 
is sero-albummous belong to this class, the effusion is gradually absorbed, 
and the patient recovers with a contraction of the side. In some in- 
stances the fluid has been evacuated by an opening through the parietes 
of the thorax, caused by ulceration or made by a surgical operation ; and 
in others again by an opening into the lung, through which the fluid has 
been expectorated. In one case that came under our own observation, 
in which the effusion was purulent, a natural cure took place by the evacu- 
ation of the fluid through an opening in the walls of the chest. This case 
occurred in a very hearty bo}', of between four and five years of age. He 
was taken sick in the country, with what was supposed to be an attack 
of typhoid fever. After many weeks of violent illness, an abscess showed 
itself in the neighborhood of the left nipple. This, at the end of two 
months, discharged, and the patient began to improve. At the end of 
three months, he was brought to town, and we saw him. We found a 
fistulous orifice, discharging occasionally considerable quantities of pus, 
just below and inside of the left nipple. The left side was very much 
contracted, and the lung was retracted into the upper part of the chest. 
He was put on cod-liver oil, wine, and nutritious food, and gradually im- 
proved. He was soon removed to the country, and we did not see him 
again, but have since heard that he had entirely regained his health. The 
recovery by absorption has been known to take place two and five months 
after the invasion. In one case that we saw, the duration from the time 
when the effusiou took place to its complete absorption was five weeks ; 
in a second it was between six and seven weeks ; in a third, six weeks ; in 
a fourth, seven ; and in a fifth, two months. 

Diagnosis. — Pleurisy may be confounded with pneumonia or hydro- 
thorax. From the latter affection it is to be distinguished by the absence 
of pain in that disease, by the existence of the effusion on both sides of 
the thorax in most cases, and by the fact that hydrothorax generally fol- 
lows as a consequence of some previous disease, particularly the eruptive 
fevers or nephritis. 

The distinction between acute pleurisy and lobar pneumonia is more 
difficult than that between pleurisy and hydrothorax, and in some in- 
stances is subject to considerable doubt. It may generally be arrived at, 
however, by attention to the differences laid clown in the following table, 
which is taken from the Bibliotheque du Medecin Practicien. 

ACUTE IDIOPATHIC PLEURISY. ACUTE IDIOPATHIC PNEUMONIA. 

Frequent after six years of age; rare Frequent after six years of age; more 

under that age. rare under that age, but much less so than 

pleurisy. 

Begins with dry cough, sharp thoracic Begins with cough, slight thoracic 

pain, bronchial and metallic respiration pain, and crepitant or subcrepitant vlion- 

during inspiration, either on the first day elms ; at a later period there is bronchial 

or later, and more rarely with obscurity respiration during the expiration and 

of the respiratory sound. bronchophony. 

Modification of the physical signs by No modification under like circum- 

change of position. stances. 



220 PLEURISY. 

ACUTE IDIOPATHIC PLEURISY. ACUTE IDIOPATHIC PNEUMONIA. 

Fever and acceleration of the respira- Fever violent ; considerable accelera- 
tion usually moderate. Eapid diminution tion of the respiration. Diminution of 
of these symptoms from the fourth to the these symptoms less marked, less rapid, 
seventh day. and not before the sixth or ninth day. 

Expectoration ahsent or very slight. Expectoration mucous; sometimes san- 

guineous; very rarely rust-colored. 
No rhonchi. Rhonchi preceding, following, and 

often accompanying the bronchial respi- 
ration. 
Absence of vibration of the thoracic Augmentation of vocal resonance very 
parietes during speaking or crying. sensible in older children, and in a less 

degree in all. 
Course of the disease irregular ; rapid Course of the disease regular; steadily 
disappearance in some cases, prolonged increasing in most cases, and then dimin- 
duration in others. The bronchial respi- ishing from the sixth or ninth day. Bron- 
ration is substituted or masked by feeble chial respiration more disseminated, 
respiration. 

In some cases, especially in young children, where the onset of pleurisy 
is very sudden and acute, the general febrile disturbance rna3 T entirely 
mask the local symptoms, and lead to the belief that some one of the ex- 
anthemata is about to develop itself. 

Thus vre have met with cases where, in the midst of full health, the 
child has been seized with violent fever ; extreme restlessness alternating 
with stupor ; repeated vomiting ; great frequency of pulse ; acceleration of 
respiration ; but with little or no cough and no complaint of pain in the 
side. In one instance of this kind, the heat of skin, rapidity of pulse, 
and frequency of the vomiting were so marked that for twentjvfour hours 
we suspected the approach of scarlet fever, and not until the second day 
were we able to satisfy ourselves of the nature of the attack b}' observing 
that the act of respiration was evidently painful, and b} r detecting the 
physical signs of plastic pleurisy over the right apex posteriori}'. 

In 2 cases, one at the age of 3 months, the other at 1^- years, we have 
observed most excessive and almost tetaniform reflex irritability, so that 
the slightest movement of the child's body, or the attempt to examine the 
chest, would provoke violent startings and spasmodic contractions of the 
entire body. In both of these cases a fatal result followed, and post- 
mortem examination revealed the presence of localized enip3< ema. 

The chronic form of pleurisy with extensive effusion, may be easily dis- 
tinguished by the history of the case, by inspection, palpation, and men- 
suration of the chest, by the nearly total absence of sonority and of the 
respiratoiy murmur except at the inner edge of the scapula, and by at- 
tention to the character of the general s^ymptoms. 

Prognosis. — Acute pleurisy is rarely a fatal disease in healthy sub- 
jects. When it occurs as a complication of some other malad}-, on the 
contrary, it is much more apt to terminate unfavorably. The degree of 
fatality in secondary cases will depend, of course, in great measure, on 
that of the primary disease. Pleuro-pneumonia is a more dangerous dis- 



TREATMENT — BLOODLETTING. 221 

order than either alone. Of 5 cases of primary plenro-pneumonia, ob- 
served by Eilliet and Barthez, 2 died; while of 10 secondary cases, 8 died. 

Of the 2S cases that we have seen, 5 died. The 5 "fatal cases were all 
primary ; 4 of them occurred in infants, 2 at 6 weeks, and the others at 
13 and 18 months respectively, and the fifth was a case of double pleurisy 
in a boy between four and five years old. Of the 23 children that re- 
covered, one was between 1 and 2 3 T ears of age ; one between 2 and 3 ; three 
between 3 and 4 ; while eight were between 4 and 5 years of age, and the 
remainder over that age. In our experience, therefore, the mortality was, 
as might have been expected, much greater in those cases occurring at a 
very early age. 

Chronic pleurisy is generally a serious, and. not un frequently, a fatal 
disease. Of 5 cases, observed by the authors, MM. Rilliet and Barthez, 
2 proved fatal. 

Treatment. — The hygienic treatment in this, as indeed in all the dis- 
eases of children, is of the utmost importance, and ought to be regulated 
by the practitioner himself. In all forms of the disease, the child should 
be carefully protected from cold, and in the acute form, kept at rest, and. 
if possible, in bed. The diet must be very strict, and should consist for 
a few da}'s of the preparations of milk. After the fever has disappeared, 
bread and milk, vegetable soup with a few oysters boiled in it to make it 
agreeable, and gradually rice, potatoes, and at last small quantities of 
meat, may be allowed. In the chronic form the diet ought to be nutri- 
tious, but regulated with equal care, as to quantity and material. In 
that form the patient should be taken into the air if the weather be mild 
and dry, and in winter the chamber ought to be well aired from time to 
time. 

Bloodletting. — Local depletion ought to be employed in the early stage 
of acute pleurisy, as a general rule. Blood may be drawn either by cups, 
or leeches, the quantity to be regulated by the age and constitution of the 
patient. From two to four ounces may be taken generally from a child 
between four and six years of age. It is seldom necessary to repeat the 
operation ; when, however, the acute symptoms are not at all relieved by 
the first detraction, it would be proper and useful to resort again to a 
small leeching, or cupping, as recommended in the article on pneumonia. 

Depletion in any form ought to be avoided in most of the secondary 
cases, unless the symptoms are very acute and the child strong and vigor- 
ous ; also in all chronic cases, after the febrile symptoms have been dis- 
sipated, and in feeble, delicate children. 

Antimonials — Febrifuges — Opiates A moderate use of the antimo- 

nials is of great service in the acute stage of the disease. Small doses of 
antimonial wine and sweet spirits of nitre, or fractional closes of sul- 
phurated antimony, as recommended in the article on pneumonia, will 
generally cause the fever, dyspnoea, and cough to subside rapidly. Large 
doses are unnecessary in any case, and are liable to be injurious in all. 

In cases in which antimonials ought not to be used, as whore they are 
opposed by some idiosjmcrasy, in children of low vital force, and in the 
secondary form, we have found a citrate of potash mixture, containing 



222 PLEURISY. 

ipecacuanha and opium, and digitalis, when the heart is much excited, 
very useful. The quantity of opium must be proportioned to the pain. 
When this is severe, the doses must be fall. The good effects of this 
remedy, in serous inflammations, are now generally acknowledged. At 
two 3 r ears of age, one drop of laudanum in the above mixture, every two 
hours, or half a grain of Dover's powder, with the twelfth of a grain of 
sulphurated antimony, every two hours, until a decidedly tranquillizing 
effect is obtained, may be used. When positive drowsiness has been 
brought about, the doses ought to be given at longer intervals — every 
three or four hours. 

Mercury. — In former years mercury was constantly employed in con- 
junction with bloodletting. In our last edition we opposed its use as 
unnecessary in acute cases, but stated that there was high authority for 
employing it in cases of the acute form tending towards the chronic, and 
in confirmed chronic cases ; adding, however, that we had not found it 
necessaiy even in these. We find, now, that Dr. West, of London, still 
speaks highly of it. He sa3'S (Joe. czY., p. 303): "After depletion, our 
chief reliance is to be placed on calomel, which should be freety given in 
combination with opium or Dover's powder; and an attack of pleurisy 
thus treated, will often be cut off in thirty-six or forty-eight hours." Dr. 
J. Lewis Smith, of New York (Joe. cit., p. 279), does not even mention 
mercury in his remarks on treatment. Dr. Thomas Hillier (Diseases of 
Children, Amer. ed., 1869, p. 87) sa} T s: "Formerly I gave mercury to all 
cases of primary pleurisy, but this practice I have discontinued, except 
in the form of an aperient. Instead of it, salines, such as acetate of am- 
monia, nitrate of potash or soda, the citrate of potash, and nitrous ether, 
are given." 

The experience we have had, since we last wrote, has not at all in- 
creased our faith in this remedy. We believe that as time goes on, and 
knowledge grows, there is good reason to think that the good effects 
formerly ascribed to calomel in such a variety of diseases, were due to 
the medicines given with it, and particularly the opium (without which 
it was not often used), the ipecacuanha, the salines, and even the anti- 
monials. 

The remedies employed b} r ourselves, after the disappearance of the 
acute symptoms, when the effusion has taken place, and especially if 
there seems any tendenc} T for the case to pass into the chronic form, are 
either iodide of potassium in syrup of sarsaparilla, according to the fol- 
lowing formula : 

R. — Potass. Iodidi, gr. xvj. 

Syrup. Sarsap. Comp., 

Aquae, aa, fgj.— M. 

Dose, a teaspoonful three times a day; 

or, the syrup of the iodide of iron, of which from thirty to sixty drops 
should be substituted for the iodide of potassium, in such a mixture as 
the above. The iodide of potassium is preferable in the early stage. 
After a time, and especially in ansemical and delicate patients, the iodide 



TREATMENT — PARACENTESIS. 223 

of iron should be substituted. Under this treatment, combined with the 
application of a Burgundy pitch plaster to the side, or some other form of 
counter-irritant, the effusion has usually disappeared in from two to eight 
weeks, though diuretics ma}' have failed to make any impression on the 
cases. 

Diuretics are highly recommended in the treatment of cases in which 
effusion has taken place. Those chiefly employed are squills, digitalis, 
and nitre. The squill is given alone, or in combination with digitalis, 
and by some with calomel, or with both. The dose of the powder of squill 
or digitalis, is about a quarter of a grain every two or three hours. The 
squill may be used also in the form of syrup or oxymel, and the digitalis 
in tincture. These two substances may be employed in the following 
formula : 

R.— Acet. Scillae, fgij. 

Tinct. Digitalis, . . . . . . gtt. xxx. 

Aquae Fluvial, f^iv.— M. 

Of this a teaspoonful is to be given three or four times a day to children 
two years old. This formula was made use of for several days in two of 
the cases referred to, without any perceptible diminution in the amount 
of the effusion, whereupon it was suspended, and the iodide of potassium, 
and afterwards the iodide of iron, as above recommended, substituted, 
and with much better effect. 

Purgatives ought to be used during the acute stage of pleurisy to an 
extent sufficient to keep the bowels soluble, and to act as mild evacuants. 
In chronic cases, on the contrary, they are particularly recommended as 
evacuants, in order to deplete the bloodvessels, and thus hasten the ab- 
sorption of the effusion. So far as our experience goes, this treatment 
is unnecessary, as diuretics and alterative tonics are generally sufficient, 
without a resort to violent remedies, which must irritate the intestinal 
mucous membrane, always extremely susceptible in children, to a dan- 
gerous degree. 

External Remedies. — Blisters are very generally employed, in the acute 
form, to relieve pain and dyspnoea, and, in the chronic, to hasten the ab- 
sorption of the effused liquid. We did not apply them in the cases under 
our charge, having succeeded very well without ; but would not hesitate 
to make use of a small one, applied for a not longer period than two hours, 
if the pain and oppression persisted. In chronic pleurisy, the application 
of a large Burgundy pitch plaster, made rather weaker than what is used 
for adults, and large enough to cover nearly the whole side, would be 
preferable to blisters. 

Tonics are often necessary in chronic, and sometimes, after the febrile 
S}^mptoms have subsided, in acute cases occurring in feeble and delicate 
children. The most suitable are quinine, in the dose of a grain morning 
and evening, small quantities of very fine port wine, and the preparations 
of iron. 

Paracentesis. — Since the last edition of this work, the operation of 
paracentesis in cases of pleurisy, both acute and chronic, has been per- 



224 PLEUKISY. 

formed so frequently and with such encouraging results, that it may now 
be considered to occupy an assured position among the remedies for 
certain conditions of this disease. It appears desirable, therefore, to 
discuss somewhat in detail the circumstances in which it is applicable, 
the indications which call for it, and to a certain extent the mode of its 
performance. In doing this, we shall avail ourselves freely of the admi- 
rable and exhaustive discussion of this operation by the lamented Trous- 
seau (Clinique Medicale, torn, i, pp. 619-698), to whose practice and 
teaching it is in great part due that paracentesis thoracis is so generally 
recognized as a justifiable operation for the relief of excessive pleuritic 
effusions. 

In acute pleurisy he recommends the operation more frequently than 
most authorities consider necessary. Whenever, indeed, the effusion 
becomes so excessive as to almost entirely fill the pleural sac on the 
affected side, displacing the adjacent viscera seriously, whether the 
patient presents intense dyspnoea or not, he advises its performance. 
The reasons urged by him for this practice are that although ordinary 
cases of acute pleurisy almost invariably recover, yet when such exces- 
sive effusion exists, it may prove fatal in more than one way. It has 
not very rarely happened that, from the obstruction to respiration, con- 
joined with the embarrassment of the heart's action due to its twisting 
and dislocation, death has occurred suddenly, and we have met with the 
records of several cases in children which had this unfortunate and un- 
expected termination. 

Again, in these cases of excessive serous effusion, if the fluid be not 
removed either by absorption or paracentesis, there is great danger that 
the case will be converted into one of empyema, not from the actual 
conversion of serum into pus, but from the altered condition of the secre- 
tion from the pleural surface. 

But even when the fluid does not become thus converted into pus, but 
remains clear and serous, absorption is. very slow, and the patient may 
perish from exhaustion and hectic fever. During the long time necessarily 
occupied in the absorption of the fluid also, the pleurisy really becomes less 
and less curable, since the lung contracts such close and dense adhesions 
as prevent it from ever fully expanding again. Finally, if any tubercu- 
lous diathesis exists, the long course of the pleuritic attack favors very 
greatly the development of phthisis. 

The chief objections which haA-e been urged against the performance 
of paracentesis in these acute cases are that the effusion will form again 
rapidly, requiring repeated punctures and exhausting the patient ; that 
the operation prolongs the duration of the case ; and that there is danger 
of converting the serous effusion into a purulent one. 

In regard to the first of these, however, experience has shown that in 
many cases a single puncture is sufficient, and that even when the fluid 
does reaccumulate, it is scarcely ever to such an extent as to demand a 
repetition of the operation. 

There is, again, no reason for supposing that the puncture, if properly 
performed, can in any way tend to prolong the case. In regard to the 



TREATMENT — PARACENTESIS. 225 

last objection, the eases recorded sufficiently show that if care be taken 
to prevent the admission of air, there is not much reason to apprehend 
the conversion of a serous into a purulent collection, unless the constitu- 
tional condition is so impaired that in all probability the case would have 
passed into one of extensive empyema, had the operation not been per- 
formed at all. Indeed, it is proved by the direct experiments of N}^sten 
and Hewson, that air injected into the pleural cavity does not the least 
harm to the serous membrane. 

In view of the various risks incurred in these cases of excessive serous 
hvdrothorax, Trousseau thus sums up his remarks upon the operation : 
"Whenever auscultation and percussion reveal the presence of a very 
large effusion, whether its formation has been attended with acute symp- 
toms or not, which interferes seriously with respiration, even though dysp- 
noea is not marked ; and when this effusion tends to increase, despite the 
active employment of local and general remedies for nine or ten clays, the 
operation is indicated." He especially directs attention to the fact that 
the mere amount of d3 T spncea must not be taken as a guide, since this may 
be absent, although there are at the same time evidences of grave inter- 
ference with the oxidation of the blood. If, however, during the exist- 
ence of such an effusion, spells of suffocative dyspnoea should ensue, or 
syncopal attacks, the operation is urgently called for. 

In the London Hospital Reports for 1865, these views are warmly advo- 
cated and powerfully supported by Dr. Fraser, who believes that the oper- 
ation should be more generally employed than at present. 

We have already alluded to the fact that occasionally an extensive 
effusion will remain serous for a long time, but in the majority of cases, 
and especially in children, it sooner or later becomes transformed into 
pus. Indeed, so frequently does this occur, that West expresses his 
conviction that in every case of idiopathic pleurisy in childhood, in which 
fluid is poured out in considerable quantit}^ the effusion is either origin- 
ally purulent or becomes so very speedily. In these unfortunate cases, 
where there is little or no disposition to absorption, where marked hectic 
fever and exhausting night-sweats soon set in and rapidly debilitate the 
patient, and where the most favorable result that can be hoped for is that 
the pus will either evacuate itself externally, or open into the lung and 
be expectorated, the operation of paracentesis should be undoubtedly 
performed. 

It is evident, indeed, that paracentesis must here have many advan- 
tages, since in cases where the pus discharges externally spontaneously, 
it is almost invariably about the fourth intercostal space, and outside of 
the nipple, at a point therefore which renders it impossible for the pus 
to freely evacuate itself, and which thus tends to keep open the fistula 
for a very long time. Again, it not rarely happens in these cases that 
the fistula does not lead directly into the pleural cavity, but the pus has 
burrowed in the thoracic walls, leading to denudation and necrosis of 
the ribs or sternum.. 

The termination by the establishment of a pulmonary fistula, and the 
evacuation of the pus through the bronchial tubes, is a comparatively 

15 



226 PLEURISY. 

favorable one, but j T et the case is apt to be more tedious, and certainly 
the lung-tissue must be much more seriously affected than when a free 
exit is given to the matter by the operation of paracentesis. In these 
cases, of course, the effusion will almost certainly form again, and either 
require repeated punctures, or a fistula will be established, through which 
pus will discharge almost dairy. 

In addition to the advantage afforded by relieving the system of this 
source of irritation, and giving the lung a chance to expand, paracentesis 
enables us also to introduce medicated fluids into the thorax, and thus to 
modify the diseased surface. We will detail below the injections which 
appear to us most useful for this purpose. 

Although, under the most favorable circumstances, empyema is a most 
dangerous and not rarely fatal affection, numbers of cases are on record 
in which life has been undoubtedly saved by a recourse to this operation, 
and it has been noticed that the proportion of success is much greater in 
cases of children than of adults. Thus, out of 46 cases in childhood, 
13 of which occurred in West's practice, no less than 35 terminated favor- 
abfy, there being 1 death in every 4 cases. 

In a recent paper by M. Guinier, of Montpellier (Bull, de VAcad. de 
Med., t. xxx, p. 645 ; Bien. Retrospect of Neiv Syd. Soc., 1865-6, p. 152), 
the particulars of 31 cases from different authors are recorded. The 
patients were of all ages up to 14 years; as many as 16, however, were in 
their Tth, 8th, or 9th year. In one of his own cases, a rapid recovery 
was effected in a case of extensive sero-purulent pleural effusion in a 
nursing child one year old. The mortality was about 1 in 6 ; and in no 
instance does the operation appear to have done any harm, but, on the 
other hand, seems to have relieved suffering and retarded death even in 
the fatal cases. 

One reason of this greater success in earfy life possibly is, that the 
much greater mobility of the chest-walls in children allows a rapid con- 
traction of the thorax to occur after the pus has been withdrawn, so 
that the chest-wall comes in contact with the lung, which, in such cases, 
is alwa} T s bound down b}^ dense and strong adhesions ; whereas, in adults, 
the more unyielding character of the thorax maintains a space between 
the two layers of pleura for a much longer time. 

The great deformity of the thorax which ensues upon empj-ema in child- 
hood is rarefy permanent, but as the lung slowfy expands, the thoracic 
walls gradually regain their normal shape, the depression of the shoulder 
disappears, and in the course of a few years at the farthest, scarcely any 
trace of distortion or contraction remains. 

In regard to the performance of the operation itself, the chief source 
of difficulty lies in the necessity of excluding air ; though this precaution 
is onfy necessary in cases of serous effusion, since where paracentesis is 
performed for empyema it almost invariably happens that sooner or later 
the pleural sac communicates with the external air. 

The procedure recommended by Trousseau is as follows : The patient 
being placed near the edge of the bed in a semi-recumbent posture, his 
body steadied by an assistant, a small incision is made through the skin 



TREATMENT — PARACENTESIS. 227 

in the sixth or seventh intercostal space, a little outside the line of the 
external border of the pectoralis major. An ordinary trocar, the canula 
of which is protected by a valve of goldbeater's skin, thin gutta-percha, 
or a piece of animal membrane of any kind, is then placed in this wound 
and thrust boldly into the pleural cavity, the precaution being taken of 
grasping the instrument so that not more than one inch shall be free, to 
avoid all possibility of wounding the lung. 

It is necessaiy that the thrust given to the trocar should be fearless 
and quick, since if it be pushed in a hesitating way, the point may push 
before it the layers of false membrane which probably coat the pleura, 
and the effusion will not be reached. Should this accident occur, an 
attempt may be made to break through the false membrane by a probe 
introduced through the canula, or a second puncture must be made in a 
different place. 

Different opinions exist in regard to the advisability of withdrawing 
the entire effusion at once, but experience has, we believe, shown that no 
unfortunate results need be apprehended from so doing. The last portions 
of fluid which escape are apt to be stained with blood, probably from rup- 
ture of the delicate new-formed vessels of the false adhesions. 

The dressing of the wound should be as simple as possible, consisting 
merely of closing the incision by a piece of adhesive plaster, over which 
a pledget of lint may be secured by a bandage round the thorax. 

Almost the only unpleasant symptom which follows the removal of the 
fluid is spasmodic cough, which often comes on in severe, and at times 
painful paroxysms. Syncope is scarcely ever noticed, if the patient be 
kept in a state of absolute rest after the operation. The internal reme- 
dies, especially the diuretics, should be continued, and Trousseau recom- 
mends that the side should be painted with tincture of iodine. 

When we have reason to believe that the effusion is purulent, which, as 
we have already remarked, is very frequently the case in childhood, there 
are some points of difference in the operation. Thus we can have no 
hope that the effusion will not form again, and either require a second 
operation, or, as frequently happens, cause the cicatrix of the first punc- 
ture to reopen. Again, before the case is brought to a successful termi- 
nation, it is usually necessary to employ some medicated injections to 
alter the character and secretion of the pleural surfaces. 

It is doubtful, therefore, whether the admission of a small quantity of 
air is very objectionable, although West believes that it almost always 
converts the previously healthy pus into a highly offensive sero-purulent 
discharge. The ill effects of this can be overcome by the injections to be 
recommended below ; but, on the other hand, care must be taken not to 
admit so much air as would interfere with the expansion of the lung. It 
is advisable on the whole, however, to perform the first puncture with 
the same care, and to employ the same dressing as in the case of serous 
effusion. But if a second puncture is required, or if the first one reopens, 
the wound should be enlarged so as to admit a good-sized canula, which 
should be allowed to remain. This canula should be of silver, curved so 
that its extremity may not come in contact with the gradually expanding 



228 PLEURISY. 

lung; and its shield should be furnished with a ring of caoutchouc, placed 
between the instrument and the skin, to prevent excoriation. 

After the pus has been withdrawn, the pleural cavity may be washed 
out through the canula with tepid water, and then there ma}* be injected 
about an ounce of a mixture of 1 part of tincture of iodine to from 4 to 
1 parts of tepid water, effected by the aid of a little iodide of potassium. 

The canula should then be closed by a cork, and not disturbed for 
twenty-four hours, when the accumulated pus should be withdrawn, and 
a second injection practised. In the first injections it is better probably 
to allow the iodine solution to run out again ; but after we have assured 
ourselves of its effect, it may be allowed to remain. Throughout the con- 
tinuance of the treatment the pus should be allowed to escape at least once 
every day. though as the secretion diminishes the iodine injections may 
be practised only at longer intervals, as once in two, three, or four days. 
The effects of these injections are usually very beneficial ; they correct 
the fetor of the discharge, diminish its amount, and never, so far as we 
are aware, are productive of pain or increased inflammation. In cases 
where they appear to have lost their good effects, other agents may be 
substituted, as weak solutions of carbolic acid, chlorinated soda, or aro- 
matic wine. 

In cases which terminate favorably, the discharge diminishes gradually, 
though often very slowly, the chest contracts, and finally there is nothing 
left but a fistula, which for a short time discharges a few drops of serous 
pus before healing. As an example of the tolerance to this treatment 
shown even by young children, and of the good results finally obtained in 
many desperate cases, we would refer the reader to the extraordinary case 
recorded at length in Trousseau's Clinique Medicate (t. i, pp. 650-52), 
where, in a boy of 6 years, the canula was allowed to remain for eleven 
months, during which time medicated injections were constantly em- 
ployed. The amount of pus discharged in all is estimated by Trousseau 
as not less than 80 pounds, and yet perfect recovery finally ensued, and 
at the date of the report the child's health was excellent. 

During the course of such cases, every attention must be paid to sus- 
taining the child's nutrition by abundant nourishing food, stimulus, if 
needful, bitter tonics, iron, and cod-liver oil. 

We subjoin the following case to illustrate the remarks we have made 
upon the treatment of pleurisy, and to show the importance of faithfully 
employing suitable internal remedies before resorting to paracentesis, in 
cases where the effusion is serous and not so excessive as to seriously 
embarrass respiration. 

Case of chronic pleurisy of the left side, beginning with acute symp- 
toms; extensive effusion, with displacement of the heart to the 7*ight of the 
sternum; recovery. — February 12th, 1846. The subject of the case is a 
bo^y four years old, of delicate stature and appearance, but enjoying good 
health. We saw him first at 1 p.m. He was perfectly well yesterday, 
slept soundly last night, and rose apparently in good health this morn- 
ing. He. ate his usual breakfast, but complained afterwards of feeling 
unwell. Soon after this he complained of headache, of soreness and 



case. 229 

weakness in the knees in going up stairs, and then of violent pain in the 
left side beneath the armpit. 

At the time of our visit, he was in bed, in the following condition : 
pulse 130, full and strong; skin warm and moist; headache; sharp, severe 
pain at the prsecordia, extending backwards under the armpit, and aggra- 
vated by motion, crying, and by deep inspirations; respiration quick and 
jerking. Xo cough at all; absolutely none. Abdomen natural ; neither 
vomiting nor diarrhoea. Tongue slightly furred and moist. Action of 
heart violent ; impulse strong and felt over a large space ; sounds loud 
and strong; to the left, and beneath the nipple, a soft murmur with the 
second sound. Percussion dull over a larger space than natural. 

Behind, percussion dull over whole of left side; natural on right side. 
Respiration natural on the right side; feeble and indistinct, without bron- 
chial sound, on the left. 

Ordered a teaspoonful, each, of extract of senna and syrup of rhubarb, 
to be given immediately ; to have a warm bath in the evening, and to 
take one of the following powders every two or three hours, beginning 
in the evening : 

R.— Pulv. Opii et Ipecac, gr. iij. 

Potass. Nitrat., ...... gr. vj. 

M., et div. in chart, no. vi. 

February 13. Passed a restless night. Better to-day. Pulse 130; 
softer; skin moist. Impulse of heart less violent. Pain not so severe. 
Respiration still quick, and when the child is excited or irritated, it be- 
comes jerking, while at other times it is quiet. Physical signs as before, 
except that the murmur, with the second sound of the heart, is no longer 
heard. Ordered three ounces of blood to be drawn by leeches from the 
left side ; powders to be continued so as to allay restlessness and pain. 

February 14. Has had a better night. Pulse less frequent. Respi- 
ration 30, and without jerking; no cough at all; makes no complaints of 
pain. The appetite is returning. 

February 15. Better in all respects; no fever nor pain; no cough. 
Physical signs as before. 

The case went on until the 2tth of March, when we paid our last visit, 
making the whole duration of the case over six weeks. During the last 
two weeks of February, there were no acute symptoms. The fever had 
disappeared entirely. The respiration continued, however, from 28 to 
30 during all that time. The effusion occupied nearly the whole of the 
left side, which was manifestly larger than the right, and the intercostal 
spaces were protruded. Behind, there was total flatness on percussion, 
from the spine of the scapula downwards, and in front from a short dis- 
tance beneath the clavicle. The respiratory murmur was absent in the 
lower three-fourths of the dorsal region, and feeble above. In front, res- 
piration was heard only above and just beneath the clavicle. In the course 
of this period the heart was gradually forced over to the right side of the 
sternum, so that at last its impulse was felt, not to the left, but to the 
right of the sternum. The cardiac pounds were loudest and most distinct 



230 HOOPING-COUGH. 

in the same region. The displacement was so remarkable that the mother 
discovered it herself, as we had avoided telling her, to save her from 
anxiety. The new position of the heart did not seem to produce any in- 
convenience in addition to that occasioned by the pleuritic effusion. Dur- 
ing the last two weeks of March the child was kept in bed ; his diet was 
milk and bread; a large Burgundy pitch plaster was kept on the side, 
and he took internally, vinegar of squill and tincture of digitalis. 

Finding that the effusion remained stationary under this treatment, we 
prescribed a grain of iodide of potassium three times a day, in a tea- 
spoonful of compound syrup of sarsaparilla. The diet was changed at 
the same time. He was allowed small quantities of meat every day, and 
was taken from bed and placed in a chair by the window. Under this 
treatment he gradually improved, so that by the 2tth of March, when we 
paid our last visit, the effusion had in great measure disappeared, and he 
was able to play about the room all da}'. The side was slightly contracted ; 
the respiration was pure and vesicular, but rather more feeble than on the 
left side ; the heart had returned to its natural position. 

We examined this child in the course of the year 1852, and found him 
to be in excellent health. Excepting a slight contraction of the left side, 
there was no perceptible difference between that side and the right. 



AETICLE Y. 



Definition; Synonymes; Frequency. — Hooping-cough is character- 
ized by a hard, convulsive cough, occurring during expiration, and ac- 
companied by long, shrill, and laborious inspirations, which are called 
hoops. The cough occurs in parox3^sms, which are terminated by the 
expectoration of tough phlegm, and often by vomiting. 

The disease is known by various other names, of which the most com- 
mon are tussis ferina, chincough, and kincough. The frequency of the 
disease is exceedingly variable, as it occurs both in the sporadic form 
and as a widely-prevailing epidemic. Some idea of its frequency may be 
gained from the facts that, during the five years from 1844 to 1848, in- 
clusive, there were 390 deaths from it in Philadelphia, under 15 years of 
age, out of a total mortality of 31,162. During the past five years, 1864 
to 1868 inclusive, there have been out of a total mortality of 76,354, 543 
deaths from hooping-cough; a proportion considerably smaller than that 
during the first period of five years above-mentioned. The irregularity is 
even more strikingly seen by comparing single years with each other : 
thus, while in 1861, there were but 65 deaths from this cause, there were 
no less than 208 in 1862. 

Causes. — Age. — It occurs generally in children, and may be met with 
in the first weeks of life ; indeed, Watson, in his lectures, mentions a 



CAUSES— AGE — SYMPTOMS. 231 

during the last week of her pregnancy, lived in a 
house where the disease was prevalent, and her infant hooped the very 
day it was born. Of 208 cases in children, in our own private practice, 
26 occurred in the first year of life, 147 between the ages of 1 and 7 years, 
and 35 between 7 and 12 years. To be more explicit, we will state that 
of 1SS cases in which the age was accurately noted, 11 occurred in the 
first six months of life ; 9 between 6 and 12 months ; 30 in the second 
year : 17 in the third, 32 in the fourth, 17 in the fifth, 30 in the sixth, 18 
in the seventh. 13 in the eighth, 8 in the ninth, 3 in the tenth, and 1 in 
the eleventh and twelfth years of life each. Of 130 cases in children, col- 
lected bj- M. Blache, 106 occurred between 1 and 7 years of age, and only 
24 between 8 and 14. Of 29 cases observed by MM. Rilliet and Barthez, 
there were 26 between 1 and 7 years, and 3 between 8 and 12. It is stated 
by MM. Blache, Rilliet and Barthez, and Valleix, to be most common in 
girls. Of 208 cases observed b}' ourselves, 106 occurred in boys, and 102 
in girls. Some writers have asserted that certain constitutions and heredi- 
tary influence predispose to the disease. So far as our own experience 
goes, it has seemed to attack indifferently those who were simultaneously 
exposed to it. The fact of its being propagated hy direct contagion is 
proved beyond doubt by numerous observations. We have rarely known 
one child in a family to be attacked without its extending to all the others 
not protected by having had the disease previously. That it often appears 
also in the form of an epidemic, is established by the testimon3 r of many 
writers, so that at present no doubt is entertained upon this point. 

Symptoms. — It is customaiy to describe three stages of hooping-cough. 
The first is called the stage of invasion, or the catarrhal stage ; the second 
the stage of increase, or the spasmodic stage ; and the third the stage of 
decline, which is characterized by an amendment of all the sjmiptoms. 

First stage. — The great majority of the cases begin with the ordinary 
sj'mptoms of simple catarrh. These are coryza, sneezing, slight injection 
of the conjunctiva?, and dry cough. The cough rarely has any peculiarity 
in the beginning which will enable us to distinguish it from that of an or- 
dinary cold, though some persons have asserted that thej r could recognize 
it. We have often listened with great care to the sound of coughs which 
parents supposed might be hooping-cough", but were always obliged to 
confess our inability to determine, until time gave them more decided 
characters. In addition to the symptoms enumerated, there is generally 
more languor, lassitude, drowsiness, and irritability,' than are commonly 
present in simple catarrh. In a small proportion, of cases the first stage 
is wanting, and the disease assumes its peculiar features from the^ first. 
The duration of this stage is very uncertain, and is ascertained with diffi- 
culty. Our own experience would fix it at about two weeks as the aver- 
age, though it may last undoubtedly a much shorter or longer period. 
The earliest period at which we have known the distinctive hoop of the 
disease to be heard was in three da} T s. In another case it was five days. 
We have also known it to appear at a later period than usual. In a good 
many instances it has been as late as three weeks, but very rarely later. 

Second stage. — At the beginning of this stage the disease has assumed 



232 HOOPING-COUGH. 

its peculiar convulsive and paroxysmal character. It consists of violent 
fits or paroxj'sms, or, as the} 7 are often called, kinks of cough, recurring 
after longer and shorter intervals. Just before the paroxysm the child 
seems restless, anxious, and irritable, or else keeps perfectly quiet and 
evidently tries to retard its approach. When it begins, the child, if hying 
down, rises up suddenly, or if playing about runs to take hold of some 
fixed object, b} T which to support itself during the accession. The cough 
is dry, spasmodic, and sonorous, and occurs in a succession of short, rapid 
expirations, b} 7 which the thorax seems to be emptied of all its air, with 
violent efforts. It is followed by one or two long and deep inspirations, 
which are accompanied Ivy the peculiar hoop to which the disease owes 
its name, and which are caused by the drawing of the air rapidly and 
forcibly through the narrowed glottis, which is spasmodically closed. 
During the fit the face becomes deeply suffused or even purple, and 
swollen ; the e} T es are watery, and the countenance is expressive of great 
anxiety, and after the fit is over, of fatigue and exhaustion. The latter 
symptoms are, as M. Yalleix remarks, the signs of partial asphyxia, and 
are the result doubtless of the complete expulsion of air from the thorax, 
and a consequent partial suspension of the function of haeniatosis. There 
is almost always an expectoration of colorless ropy fluid, often accompa- 
nied by vomiting, at the close of the fit of coughing, and the patients 
usually appear weak and languid for a short time, after which they return 
to their play. 

In very severe cases there are other symptoms in addition to those just 
mentioned. Hemorrhages from the mouth, ears, nose, lungs, and beneath 
the conjunctivas, are not unusual. We have ourselves seen several in- 
stances of epistaxis, one of effusion into the eyelids, a few of extensive 
subconjunctival ecclrymosis, and we are well acquainted with the history 
of another case, in which there was bleeding both from the nose and ears. 
In one case, in a girl between five and six years old, that occurred to one 
of ourselves, in which the paroxysms were violent, the spells were accom- 
panied in the latter half of the fourth and in the fifth week, by a discharge 
of a good deal of blood from the mouth. This took place particularly 
during the night-spells, so that in the morning the basin would contain 
several teaspoonfuls of blood. It was not from the nose. It was bright 
in color, pure, except that it was intermingled with sero-mucous expec- 
toration, but it was not intimately blended with the sputa, nor was it 
streaked through the mucus as it sometimes is in the pneumonia of 
children. On one occasion it was seen to fly from the mouth in a little 
spirt, as though from a vessel. The child was lively and well all this 
time, playing about, eating well, strong, not thirsty, without pain, not 
oppressed between the spells, and sleeping naturally between the parox- 
ysms at night. The only altered physical sign was slight dulness on 
percussion over the upper part of the right lung behind, with some sub- 
crepitant rale at that point, but without bronchial respiration. After 
lasting twelve days, it ceased ; the child got well gradually, and continues 
strong and hearty to the present time. The attack occurred in January 
and Februaiy of 1849. In another, in a girl two years of age, which 



SYMPTOMS. 233 

came under our own observation, a species of syncope, a state of insen- 
sibility without convulsive movements, accompanied by great paleness, 
occurred after many of the paroxysms. 

We have met with general convulsions in 12 cases, 5 of which proved 
fatal. In 2 other cases, both occurring in infants under six months, the 
paroxysms of cough were accompanied by the most violent struggling 
and oppression, and by deep blueness of the hands and feet, like that of 
severe cyanosis. 

In some instances, after the paroxj-sm is apparently over, the child will 
begin within a few instants to cough again, and may in this wa}^ have 
several fits in such rapid succession as to make an almost continuous 
paroxysm. It is quite common for this to happen twice, and in one case 
which we saw, it occurred three times on several occasions. The ordi- 
nary duration of a paroxysm or kink, is from a quarter to three-quarters 
of a minute, though it may last as long as two minutes, or according to 
some even longer. In a case that occurred to ourselves, one paroxysm 
lasted the extraordinary period of fifty-five minutes. That it was really 
a paroxysm of the disease, we are quite sure, as it chanced that we 
reached the house shortly after it began, and witnessed the greater part 
of it ourselves. The number of accessions in twenty-four hours is very 
irregular. It depends chiefly on the stage and violence of the attack. 
During the height of the disease, we have generally found them to num- 
ber about 40. In some rare cases, however, they are much more numer- 
ous, and amount to 70 or 80. They are generally most frequent in the 
course of the third or fourth week, after which they remain stationary as 
to frequency for several days, or for two or three weeks, and then decline 
gradually. The paroxj-sms may occur spontaneously, the child being 
often disturbed from sleep by their sudden occurrence, or they may be 
excited hy various circumstances, such for instance as contrarieties, a fit 
of crying, change of position, eating, violent exercise, and imitation. We 
have frequently seen an attack brought on b} r the sight of another child 
in a paroxysm of the disease. The duration of the second stage may be 
stated to be about 30 or 40 days in most cases. 

Third stage. — It is impossible to fix a precise limit from which to date 
the beginning of this stage. It is generally, however, said to commence 
from the time when the disease is evidently on the decline. The par- 
oxysms now grow less frequent and less violent, the cough reassumes 
some of the catarrhal features which it had at first, and gradually loses 
its peculiar spasmodic character. The child's general health improves, 
the appetite becomes vigorous, the strength is invigorated, the sleep 
again becomes sound and tranquil, and the disease disappears. The du- 
ration of this stage is uncertain, like that of the two others. MM. Rilliet 
and Barthez state it to be short in uncomplicated cases (ten to fifteen 
daj's), and are of opinion that when it has been supposed to have lasted 
several weeks or months, it has been the result of some complication, 
as chronic dilatation of the bronchia, tubercular disease, &c. It happens 
not unfrequently, however, that after the disease has apparently ceased, 



234 HOOPING-COUGH. 

all the distinctive characters of the cough recur, if the child chance to 
take cold within a few weeks or even longer after its disappearance. 

In cases of pertussis unaccompanied b} r complications of any kind, 
there are no marked general symptoms. There is seldom any fever, the 
appetite continues good, and with the exception of occasional languor 
and fatigue, and irritability of temper, the child appears to be well. 

Urine. — No accurate analyses of the urine in pertussis appear to have 
been made. Gibb and Johnston, however, state that they have found 
sugar in variable quantities in almost every case. This question appears 
well worthy of full investigation, since, if this statement is confirmed, it 
would link itself in the most interesting manner with the other evidences 
in this disease of irritation of the pneumogastric nerves, which are at least 
somewhat concerned in the glycogenic function of the liver. 

The total duration of the disease, in simple cases, may be set down at 
from one to three months. We have never known a case to last so short 
a time as a month, and have rarely found the whole duration much within 
three months. 

Complications. — Though it has happened to us, on several occasions, 
to meet with children who have been very ill from the violence of the 
disease under consideration in its uncomplicated condition, we have 
never known a case to prove fatal except in consequence of some kind of 
complication. It is exceedingly important, therefore, that the A T arious 
accidents apt to occur in the course of the disease should be carefully 
considered. 

Convulsions. — This complication is not a rare one, since it occurred in 
5 of 29 cases observed by MM. Rilliet and Barthez, and in 12 of 208 ob- 
served by ourselves. It is one of the most dangerous accidents liable to 
occur in the course of the disease. Of the 1 cases reported by the authors 
quoted (5 of their own, and 2 belonging to M. Papavoine), 6 died. Of 
our 12 cases, 5 died. In all that we have seen, the convulsions were 
general, extremely violent, and accompanied by insensibility in the fatal 
cases to the last, and in the favorable ones, during from a few minutes to 
half an hour. In two of the fatal cases the pertussis had lasted nearly 
two months, and was accompanied by extensive bronchitis. The fatal 
event took place within twentj-four hours from the supervention of the 
spasms. The subjects were eight and nine months of age respectively. 
In the third case, the convulsions came on in the seventh week of the 
disease, in a child who had been laboring for a number of clays under 
bronchitis. They ended fatally in seven hours. In the fourth they oc- 
curred in a child in the second } T ear of its age, at the end of about four 
weeks, proved fatal in two days, and were caused b} 7 bronchitis and col- 
lapse of the lung-tissue. In the fifth case they occurred likewise in a 
child in the second year of life, were attended with violent laryngismus 
and contraction, and proved fatal in the third week of the disease. 

One of the favorable cases occurred in a child five months old, who had 
been attacked with bronchitis three da} T s before the occurrence of the 
convulsions, which came on during the height of a severe paroxj^sm of 
coughing. The convulsive movements were general, and continued for 



COMPLICATIONS — CONVULSIONS — LARYNGISMUS. 235 

about half au hour, after which the child was drowsy or irritable for some 
hours longer. The hooping-cough, continued to be severe for two weeks 
after this, as many as 42, 46, and 48 paroxysms occurring every clay. At 
last, however, perfect recovery took place. The second favorable case 
was that of a girl between two and three years old, in whom a convulsion 
occurred in the third week of the disease, before the paroxysms had be- 
come violent, and evidently in consequence of an attack of fever depen- 
dent upon dentition. The seizure lasted only a few minutes, was followed 
by drowsiness for a few hours, but on the following day all the unpleasant 
symptoms had disappeared. In a third case, in a boy between two and 
three years old, a violent convulsion occurred at the end of the second 
week, at the beginning of an attack of pneumonia. The child remained 
very ill, and nine days afterwards had another convulsion, which was 
much slighter than the first. After this he gradually recovered. In a 
fourth case, in a girl between two and three years old, a slight but well- 
marked convulsion occurred at the onset of an attack of bronchitis, which 
took place at the beginning of the third week of the hooping-cough. The 
bronchitis proved to be very severe, but there was no return of the spasm, 
and the child recovered. In a fifth case, in a boy nine months old, a 
severe fit occurred in the sixth week, just after the child had been brought 
home from an expedition to procure his daguerreotype. It lasted fifteen 
minutes, and was attended with total insensibility, and purple discolora- 
tion of the face, but in half an hour after, the patient was nursing well, 
and was entirely conscious. There was no return of the convulsions, 
though the disease was very severe after this attack. In the sixth case, 
also in a boy nine months old, a slight convulsion occurred during one 
of the paroxysms in the fifth week, but was not followed by any bad con- 
sequences. 

Amongst the complications ought to be ranked, we think, though this 
has not generally been clone by writers, an excessive degree of the laryn- 
gismus which constitutes one of the natural and essential features of the 
disease. In some children, in fact, and especially in those of a nervous 
temperament, and in the anemical and debilitated, and, likewise, in cer- 
tain epidemic types of the disease, this laryngismus assumes a degree of 
severity, which is not only distressing but positively dangerous. In one 
case that occurred to ourselves, in a child who had suffered many months 
before from laryngismus and contracture, the occurrence of hooping- 
cough reproduced the laryngismus, and after a few weeks caused death 
almost instantaneously, at the beginning of a paroxysm, as the child was 
sitting upon the floor, where it had been placed only a few moments be^ 
fore to play, it having presented before this no very threatening S} T mp- 
toms. In another case, in which we could detect no other complication, 
the spasm of the glottis was so very violent, that after a few clays the 
spells were attended with convulsions, and very soon ended fatally. In 
a third, this symptom was so violent that in many of the spells the child 
ceased for the time to breathe, seemed to faint, became entirely uncon- 
scious, and had to be fanned and carried to an open window to be re- 
vived; this patient ultimately recovered. In a great many cases, this 






236 HOOPING-COUGH. 

symptom without other complication, has been most distressing, and has 
required particular treatment. 

Collapse of the lung-tissue. — The recent discoveries in regard to the 
pathological change in the pulmonary tissue called collapse, and especi- 
ally a consideration of the causes by which collapse is produced, might 
well lead us to suppose that pertussis, and especially the bronchitis of 
pertussis, would be very apt to become associated with collapse. Late 
researches accordingly show that of all the lesions met with in hooping- 
cough this is much the most frequent and important. Dr. Graily Hewitt, 
of London, in a lecture on the pathology of hooping-cough, read before 
the Harveian Society of London, in 1855, shows "that the catarrhal in- 
flammation of the bronchial tubes, which occasions hooping-cough, is, in 
fatal cases, attended alpiost universally with collapse of the lungs." He 
states that his observations were made upon nineteen subjects ; whose 
age varied from four } r ears to one month, the average being eighteen 
months. "In all, the state of the lungs was carefully noted. The chief 
lesion found after death was collapse of the lung-substance. The follow- 
ing is a statement of the degree to which this pathological condition 
manifested itself in the different lobes of the two lungs. 

" In the right lung, portions of the upper lobe were found collapsed in 
six cases, and in four more to a less degree. The middle lobe was col- 
lapsed, wholly or in part, in sixteen cases. The lower lobe was more or 
less affected with collapse, in eighteen cases. In the left lung, the upper 
lobe presented the same lesion in fifteen cases, the whole of the anterior 
tongue-like prolongation being in most of the cases affected. The lower 
lobe was collapsed more or less in eighteen cases. In seven of the cases, 
the portions collapsed were also congested, in some to a high degree. 

" The test of MM. Bailly and Legendre, viz., the infiatability of the 
portions of the lung thus affected, was used in almost all the cases ; and 
on that and other grounds, it was determined, that the particular part of 
the lung in question was collapsed and not hepatized. 

" It will be at once perceived, that the occurrence of collapse was almost 
universal ; all the cases, with the exception of one, in which there was 
exteusive tuberculization of the lungs, presenting a greater or less amount 
of lung-substance affected in this manner." 

We have had but few opportunities of testing this matter for ourselves 
by post-mortem examinations ; but in one case to which we were called in 
consultation, that of a boy not quite a year old, this lesion was shown, by 
autops} T , to be present to a great extent. The child had had the disease 
during three months with considerable severity. He was thought to be 
doing well, until he was taken one day a long drive into the country. 
After the ride he seemed very much fatio-ued, and that nio-ht was seized 
with very great dyspnoea, increased violence of the coughing spells, and 
after a short time with general convulsions. We saw him on the follow- 
ing day. He was breathing very rapidly and with much effort, there was 
a good deal of subcrepitant rale through the chest, the skin was cool, and 
about the mouth had a cyanotic tint, and he was unconscious. The same 
symptoms persisted through the day with occasional convulsive seizures, 



COMPLICATIONS — BRONCHITIS — PNEUMONIA. 237 

and on the following clay lie died. At the autopsy, there was found very 
extensive collapse of both lungs, as proved both by the anatomical appear- 
ances, and by inflation. There was no pneumonia, and very moderate 
bronchitis. 

Bronchitis has alwaj^s been supposed to be the most frequent compli- 
cation of hooping-cough, and there can be no doubt that it is one of the 
most important. The recent discoveries of the existence and nature of 
collapse have shown, however, that many of the fatal cases, hitherto 
ascribed to bronchitis, or to bronchitis and pneumonia combined, must 
have been cases of collapse, so that large allowances must be made for 
all statistics collected before the discovery of the true nature of the last- 
named lesion. 

There is, as has already been stated, a certain amount of pulmonary 
catarrh in eveiy case of hooping-cough. This is a normal element of the 
disease. To constitute a complication there must be a true bronchitis, an 
inflammation of the bronchial mucous membrane, sufficient to produce the 
ordinary symptoms of that disease. This exists in a great many cases ; 
MM. Rilliet and Barthez found it to exist either alone or combined with 
pneumonia in half of the fatal cases. Of the 208 cases observed by our- 
selves, it existed to a greater or less extent in 42. In 28 of these it was 
mild or only moderately severe, and of these all but one recovered. In 
14 it was severe and very extensive, or else capillary, and of these 6 
died. Of the fatal cases, it was in several no doubt attended with col- 
lapse of the lung-tissue. In fatal cases it has often been found accom- 
panied hj continuous dilatation of the smaller bronchia. 

Pneumonia, according to the authors above quoted, is about as frequent 
as bronchitis. When, however, the fatal termination took place soon after 
the beginning of the disease (18th, 26th, or 2Yth days) it was not gene- 
rally present. After these periods, on the contrary, it was almost always 
observed. As these authors, however, include, under the title of lobular 
pneumonia, many cases of bronchitis with collapse, it is clear that a large 
number of their cases of supposed pneumonia ought to have been ranged 
under the head of bronchitis. For our own part, we have met with only 
five well-marked cases of pneumonia. Two of these occurred in girls of 
seven and nine years old respectively, one in a girl between one and two 
years of age, a fourth in a boy between two and three years old, and a 
fifth in a boy in his ninth year. They all recovered. The degree of 
danger from this complication is in proportion to the earliness of the age 
at which the disease occurs, and to the extent of the inflammation. 

Emphysema has been supposed by some to be a common result or 
accompaniment of the disease. This is denied, however, by others. We 
have never observed it ourselves, and as nearly all the children whom we 
have attended with pertussis continue under our charge, we should cer- 
tainly have noticed it, were it of common occurrence. 

Vomiting is a very frequent incident in pertussis, but ought not to be 
regarded as a complication, unless dependent on some disease of the di- 
gestive organs, or symptomatic of cerebral disease. Where it occurs in 



238 HOOPING-COUGH. 

simple cases, or in those complicated with bronchitis or pneumonia, it 
has alwaj T s seemed to us to be advantageous. 

Tuberculosis and scrofula are not infrequently found to follow hooping- 
cough, in cases where a marked predisposition to these conditions exists. 
The tuberculous affection is most apt to take the form of pulmonary or 
bronchial phthisis. These sequelae are frequently observed in hospitals, 
and among the ill-fed and feeble children of the poor, but are compara- 
tively rare among the better classes of society. 

Diagnosis. — The diagnosis of pertussis is difficult only during the first 
stage of the complaint. It is impossible, indeed, to distinguish, during 
that stage, between it and simple mild laryngitis, or the mild catarrhal 
attacks which are so common in our climate. After it has once fairly 
entered upon the second stage, it is scarcely possible to confound it with 
any other malady. MM. Rilliet and Barthez state, however, that acute 
bronchitis with paroxy smal cough is not unfrequently mistaken for per- 
tussis, and we recollect perfectly having made this mistake ourselves, in 
a little girl, five years of age. The cough assumed so exactly the features 
of pertussis, that after waiting a few da} T s, we announced, authoritatively, 
the presence of pertussis. Only three or four days after this we were 
forced to tak-e it all back, for the whole thing had disappeared, bron- 
chitis, pertussis, and all. The patient was entirely well. But the mistake 
need seldom be made, if it be recollected that in acute bronchitis with 
paroxj^smal cough, the invasion is sudden ; that there is violent fever, 
great dyspnoea, and the physical signs of bronchitis ; that the hoop is 
generally wanting, or feebly marked, and that the disease is violent and 
rapid in its course ; all of which circumstances are widely different from 
what occurs in pertussis. 

The same authors assert that tuberculosis of the bronchial ganglions 
gives rise to a cough which may be mistaken for pertussis. The follow- 
ing table extracted from their work will show the differences between the 
two disorders. 

PERTUSSIS. TUBERCULOSIS OF THE BRONCHIAL 

GANGLIONS. 

Often epidemic, attacking several chil- Always sporadic ; non-contagious, 
dren at once; transmissible by contagion. 

Three distinct stages, of which only the No distinct stages. 
second is accompanied by kinks. 

Kinks attended with hooping, ropy ex- Kinks generally very short, without 

pectoration and vomiting. hooping, ropy expectoration or vomiting. 

Pure respiration in the intervals be- Physical signs of tuberculosis of the 

tween the kinks. ganglions ; but, in certain cases, absence 

of these signs. 

In the intervals between the kinks, Accessions of asthma in some cases, 

respiration and pulse natural, so long as with the kinks ; continuous febrile move- 

the disease is simple. ment, with evening exacerbations, sweats, 

progressive emaciation, &c. 

Voice natural. Voice sometimes hoarse. 

Course generally acute. Chronic course. 



PROGNOSIS — NATURE OF THE DISEASE. 239 

Prognosis. — Pertussis is rarely a dangerous or fatal disease so long as 
it remains simple. Of the 208 cases observed by ourselves, 143 were 
simple, all of which recovered. Nevertheless even the simple disease 
does sometimes terminate fatally, from the excessive violence of the par- 
oxysms of coughing. 

The danger in hooping-cough, which is considerable, depends, there- 
fore, almost entirely on the complications which are so apt to occur, for 
which reason the physician should watch with the closest attention, in 
order to prevent their occurrence, and that he may recognize and treat 
them in their earliest stages. The most dangerous complication is con- 
vulsions, and after that bronchitis and pneumonia. So long as the child 
seems well and lively, and without fever or dyspnoea, in the intervals be- 
tween the fits, there is nothing to be feared. But if, on the contrary, it 
becomes languid and irritable, with indisposition to take food, feverish- 
ness, and some increase of the rate of respiration, the practitioner should 
be upon his guard. A very early age and natural delicacy of constitu- 
tion, are unfavorable circumstances in the disease. Some form of com- 
plication occurred in 65 of the 208 cases observed by ourselves. Of the 
65, 12 died. 

Five of the 12 fatal cases ended with convulsions. Of these 5 cases, 
the convulsions were caused b} T bronchitis and collapse of the lung in 4, 
the fatal result being the consequence, in fact, of the lung complication. 
One of the cases was independent, apparently, of disease of the lung 
(though, as no post-mortem examination was made, this cannot be as- 
serted positively), but seemed to be the result of the violent laryngismus, 
with contracture and general convulsions, such as will be described in the 
article on laryngismus stridulus. Two of the cases occurred in children 
of eight and nine months old, respectively, and proved fatal in twenty- 
four hours after the setting-in of the convulsions. Two others occurred 
in children in their second year, and the fifth occurred in a boy between 
three and four years old, and caused death in seven hours. 

Of the remaining seven fatal cases, one was the result of collapse of 
the lungs, supervening suddenly upon a mild bronchitis, in a twin child 
between two and three months old. The second was caused by tubercu- 
lar disease of the lungs, in a child between three and four years old, and 
the remaining five by bronchitis, associated, to a greater or less extent, in 
all probability, with collapse of the lung. Of the last-mentioned five cases, 
one occurred in a child between five and six months old, and was rapid 
in its course ; two occurred in children between one and two years old, one 
being rapid and the other lingering in its course ; one occurred in the third 
year of life, and was attended with severe diarrhoea from teething, as well 
as with bronchitis and collapse ; and the fifth occurred in a child in its 
fourth year, and was slow and gradual in its course. To sum up, it may 
be stated that of the 12 fatal cases, 10 were the result of bronchitis and 
collapse, 1 of tuberculosis of the lungs, and 1 of laryngismus stridulus. 

Nature of the Disease. — There is no essential anatomical lesion in 
pertussis, except, perhaps, slight inflammation of the bronchial mucous 
membrane. In most of the cases, the membrane lining the larger and 



240 hooping -couaH. 

smaller air-tubes, and very rarely that of the trachea, is reddened and 
perceptibly thicker than natural, and the tubes contain a considerable 
quantity of frotlry mucus, or a thick, viscid, and tenacious phlegm. 

As to the nature of the disease, it seems to us very clear that it ought 
to be regarded as comprising two elements of morbid action, one of which 
consists in slight inflammation of the respiratory mucous membrane, and 
the other of disordered action of the respiratory sj'stem of excito-motor 
nerves. It is neither a pure neurosis nor a pure inflammation, but par- 
takes of the characters of both, and much more of the former than of the 
latter. The authors of the Compendium de Medecine Pratique (t. ii, p. 
526) regard it as a neurosis, on the following grounds: 1. " In the greater 
number of cases the respiratory apparatus presents no kind of alteration, 
or else the lesions are so multiplied or variable, that they are surely not 
the real origin of the disease. 2. The clearly remittent course of the 
symptoms, and the total absence of fever, unless some complication is 
present, are not observed in ordinary or even specific inflammations. 3. 
The cessation or sudden return of the paroxysms, under the influence of 
moral emotions or change of place, belong to a disorder of innervation, 
and not to inflammation, which commonly passes through certain stages 
before it is resolved. 4. The complete return to health, the integrity of 
all the functions in slight cases, the resistance which it opposes to treat- 
ment, the uselessness of antiphlogistics, and the success obtained from 
narcotics and antispasmodics, are all so many circumstances peculiar to 
hooping-cough and to many of the neuroses." 

It has, however, so many points of resemblance to the various consti- 
tutional diseases, as its undoubtedly contagious nature ; the facts that it 
runs a definite course, and that one attack protects the system against a 
second ; that it also probably depends upon a morbid state of the blood, 
due to the introduction of some specific poison which possesses the pe- 
culiar power of irritating the pneumogastric nerves. 

Treatment of Simple Pertussis. — Hooping-cough, like all other dis- 
eases, varies greatly in its degree of severity. It is sometimes an affair 
of no consequence scarcely, the patient passing through its stages with- 
out suffering, and without any injurious consequences whatever to the 
general health. We have known a large family of children to pass 
through the disease without other treatment than attention to a prudent 
hygiene, and with no other medicine than a few doses of a mild cathartic, 
given to relieve some uncomfortable gastric symptoms. We have known 
one child in a family where the disease was prevailing at the time, to have 
the cough for onby five weeks, and to hoop only on two or three occasions, 
and to lose neither appetite nor spirits for a moment. Such cases evi- 
dentby need no interference, and a wise physician will, in such, order no 
drugs. His business will be simply to direct that the child be guarded 
against cold and against imprudences in diet. 

In other instances the disease assumes, from a very early period, or 
sometimes not until later, a character of a very different kind. Without 
an}' complication whatever, the natural symptoms of the disease develop 
in great intensity. The spells of coughing are very frequent, very vio- 



TREATMENT — BLOODLETTING. 241 

lent, and very long-continued. Instead of some twenty spells or less in 
twenty-four hours, as is the rule in mild and moderate cases, the patient 
will average two or more every hour, having fifty or sixty spells in the 
day. The laryngismus, instead of being slight will be violent and dis- 
tressing, so that in lieu of three, four, or five hoops in a paroxysm, there 
may be fourteen or fifteen, and these so shrill, acute, and prolonged, as 
greatly to exhaust the poor little patient. Or the laryngismus may be so 
intense as to close for a few seconds the glottis, and arrest entirely the 
respiration, giving rise to the most painful attacks of struggling and suf- 
focation possible to behold. Or the vomiting may be so frequent as se- 
riously to interfere with the nutrition of the child, and thus cause threat- 
ening and even dangerous debility. In certain families, and in certain 
epidemic types of the disease, it assumes these severe features, and such 
cases must take the same rank in this disease, that grave cases of scarlet 
fever, measles, or variola, take in those affections. 

Cases of this latter kind imperatively demand treatment, and they are, 
we are happy to state, susceptible very generally of great and striking 
alleviation, by the use of proper means, — means, too, which in themselves 
are very safe. 

At one time we were very much disposed, we confess, to avoid all in- 
terference so long as we saw no complication in the case, under the sup- 
position that the disease in its simple form was always safe, and might 
be trusted to the efforts of nature. More enlarged experience has taught 
us, however, that the very violence of the disease, even in its simple form, 
was a source of danger ; and that, moreover, such were much more liable 
than milder ones to complications, while a proper treatment, instituted 
so soon as the disease began to show these severe characters, has almost 
always, after a few days' perseverance, brought about and maintained a 
most evident amelioration of the symptoms, thus keeping within due 
bounds a development which might otherwise have gone on to a dis- 
astrous termination. 

Bloodletting. — Depletion is very rarely necessary in simple pertussis. 
The only cases in which it can be called for are those occurring in san- 
guine children, where the laryngismus is so extreme and the paroxysms so 
violent as to lead to great engorgement of the right side of the heart, and 
even to endanger the brain by over-distension of the veins. Under these 
circumstances, we might resort to venesection merely for the mechanical 
relief afforded, as recommended under similar conditions in pneumonia. 
In such cases only then, a small bleeding, or the application of a few 
leeches to the temples or behind the ears, may be proper ; but even these 
may generally be safely treated by reduced diet and by a few doses of 
saline cathartics, without a resort to the more powerful and more per- 
manently exhausting means of depletion. As for the treatment of simple 
pertussis by repeated venesections, in the hope of curtailing its duration, 
or under the idea of their being rendered necessary b} T the violence of 
the malady, it seems to us forbidden by the present state of medical 
knowledge, which informs us that the greater number of the cases do not 
endanger life so long as they remain simple, however violent they appear 

16 



242 HOOPING-COUGH. 

to be. Of the 143 simple cases treated by ourselves, depletion was not 
used in an}^ and all recovered. 

Antispasmodics. — Various remedies of this class have been empk^ed 
in this disease with apparent success. We have usually obtained such 
satisfactoiy results from other means, hereafter mentioned, that we have 
comparatively rarely resorted to these remedies. We have, however, used 
assafoetida in a number of instances with decided benefit, both in relieving 
the general restlessness and in moderating the number and severity of 
the paroxysms. The doses in which we have given it are either two or 
three grains in pill, or a teaspoonful of the mistura assafcetidse, three or 
four times a day to a child of four years old. 

Narcotics. — Of the various narcotics which have been more or less 
extensively emplo3 T ed, the most important are belladonna, opium, and 
hydrocyanic acid. Belladonna is highly recommended by several German 
authors, by MM. Rilliet and Barthez, who state that it is bej^ond contra- 
diction the one most deserving of confidence, by Trousseau and Pidoux, 
and by numerous English and American writers. MM. Trousseau and 
Pidoux employ the following formula : 

R. — Pulv. Belladonna, ...... gr. iv. 

Extract. Opii Aquos., gr. iv. 

Extract. Valeriana?, gss. 

M. et div. in pil. no. xvi. 

S. One to four in the course of the day. 

If the child dislike the pilular form, they give it in syrup, according to 
the following formula: 

R. — Extract. Belladonnas, gr. iv. 

Syrup. Opii, 

Syrup. Flor. Aurantii, aa f^j. — M. 

Of this, from one to eight teaspoonfuls are to be given in twenty-four hours. 

We have ourselves used belladonna in a very large number of cases of 
hooping-cough, and with such unquestionable benefit, that we regard it 
as one of the most valuable remedies for this disease in our possession. 

We have certainly never seen it cut short the course of the disease, as 
it has been asserted to do, but we have almost invariably found it to 
moderate the laryngismus, shorten the paroxysms and diminish their 
number, and probably also shorten the duration of the attack. We have 
not, however, been in the habit of prescribing such large doses of bella- 
donna as those quoted above (gr. \) ; but have usually given it in com- 
bination with alum, in the dose of 34th of a grain of the extract, every 
four hours to a child of one 3 T ear old. The formula which we employ will 
be found in our remarks upon the use of alum. 

Belladonna has also been largely used, especially b} T Dr. Fuller, in com- 
bination with sulphate of zinc, and with excellent results. This latter 
author states that he has observed a remarkable tolerance of belladonna 
in children, so that, beginning with quite large doses, the amount ma} T be 
rapidly, though carefully, increased until the quantity taken exceeds out 



TREATMENT — OPIUM — EMETICS. 243 

of all proportion, the corresponding doses which will be tolerated by 
adults. Even when given, however, in the comparatively small doses of 
5 » ¥ th or T Lth of a grain, it is necessary to watch for any symptoms of the 
toxic action of the drug, so that its administration may be suspended or 
the amount diminished. 

Opium is confessedly a veiy valuable remedy in the disease, not as a 
curative, but as a sedative and palliative. When the cough is frequent 
and fatiguing, especiall}~ if the patient have an irritable and nervous con- 
stitution, some opiate preparation is of the utmost service in moderating 
the frequency and violence of the paroxysms, and in allaying irritability 
and restlessness. It is best given in the evening, and in combination 
with ipecacuanha. 

Hydrocyanic acid has been employed by various observers,, and is highly 
spoken of by some. Its poisonous properties, however, have deterred 
many, and amongst them, ourselves, from resorting to it. Inasmuch as 
there are other and safer means for conducting the disease to a favorable 
termination, it seems to us useless to venture upon so potent a prepara- 
tion as this. Dr. Atlee, of Lancaster, gave it in the following formula : 

R. — Acid. Hydrocyan., i^j. 

Syrup. Simp., fgj.— M. 

A teaspoonful to be given morning and evening, and if no uneasiness,, 
dizziness, or sickness be produced within forty-eight hours, the close to 
be repeated three times a day. This prescription is for a child six months 
old ; one drop of the acid being added for each year of the child's age 
beyond one }'ear. He has never repeated the dose more than four times 
a day. (Condie's Dis. of Child., 2d ed., p. 337.) 

Emetics and ^auseants are amongst the most important remedies in 
the treatment of hooping-cough, since they exert a powerful influence- 
upon the disease, and unless carried to excess, are not in themselves 
likely to be injurious. Some authors recommend the administration of" 
an emetic every day or every other da}^, while others give them accord- 
ing to the necessity of the case. Believing that frequently repeated, 
emetic doses are unnecessarily severe, and productive of too much fatigue 
and exhaustion, we have preferred in the simple disease to give only small 
doses of ipecacuanha from time to time, so as to moderate the violence of 
the cough. Tartar emetic is never necessary, and ought to be avoided, 
on account of its disposition to irritate and inflame the gastro-intestinal 
mucous membrane, and because of its exhausting effects on the general 
economy. The syrup of ipecacuanha is the preparation we have almost 
always used. From ten to twenty drops, given three times a day to a 
child three years old, will very generally moderate the severity of the 
paroxj'sms. 

Purgatives are necessary in the simple disease only when constipation 
is present. The mildest ought to be preferred, in order to avoid irrita- 
tion and exhaustion. Castor oil, magnesia, or syrup of rhubarb are the 
best. 



244 HOOPING-COUGH. 

Particular Bemedies. — Of the different specific remedies that have been 
employed, none have attained and maintained so high a reputation in 
this city as the carbonate of potassa. which, in the form of the cochineal 
mixture, is constantly used both \>y plrysicians and as a domestic rem edy. 
The beneficial effects of this drug are equally recognized abroad, as ma}^ 
be judged from the language of Memeyer who, when speaking of its use 
in hooping-cough {op. cit, vol. i, p. 101), says, "its effect in shortening 
the fits of coughing is often surprising." The following formula is the 
one generally administered: 

R. — Potass. Carbonat., £j. 

Coccii, £)ss. 

Sacch. Alb., gj. 

Aquae fontis, f^fiv. — M. 



mg 



Give a dessertspoonful three times a day to a child a year old. Believ 
the carbonate of potash to be the active agent in the mixture, we have 
generally left out the cochineal and used the potash alone, dissolving it 
in equal parts of syrup of gum and water. We have frequently erupk^ed 
this remedy, and believe that it, with alum and belladonna, are the most 
useful agents we have to keep down the violence of the disease. We 
have given it in the dose of a grain three or four times in the twenty-four 
hours, to children one and two j^ears old, for several weeks at a time, 
without witnessing ^nj injurious effects from it. 

Alum was first highly recommended as a remedy in pertussis by Dr. 
Golding Bird (Guy's Hospital Reports, April, 1845). He states that in 
the second or nervous period of the disease, when " all inflammatory 
s} y mptoms have subsided, and when, with a cool skin and clean tongue, 
the little patient is harassed by a copious secretion from the bronchi, the 
attempt to get rid of which produces the exhausting and characteristic 
cough, alum will be found to be of much value." He acids, that he "has 
not yet met with any other remedy which has acted so satisfactorily, or 
afforded such marked and rapid relief." From reading Dr. Bird's remarks 
on alum, and prompted by our knowledge of its admirable qualities in the 
treatment of croup, we were formerly led to make trial of it in the dis- 
ease under consideration, and we believe we may say that it has exerted 
a more decided influence in moderating the violence of the disorder, than 
any that we have ever made use of. We have administered it in 139 cases, 
beginning in the course of the second stage. In nearly all it was bene- 
ficial, and in some the effects were strikingly useful, the improvement 
being more rapid than we had ever seen to result from other remedies, or 
to occur when the disease has been allowed to pursue its natural course. 
In a boy, between five and six years of age, who had been coughing vio- 
lently for two weeks, the paroxj-sms diminished so much in intenshVv and 
frequency, after he had taken the remedy two da} r s, that he was not once 
disturbed at night (though before he had always been waked several 
times), and the spells which occurred during the day were much less 
severe. After continuing the remedy for ten days, the disease had sub- 
sided so much that its einphyyment was suspended. Soon after, however, 



TREATMENT — ALUM. 245 

the paroxysms again became severe and troublesome. The alum was re- 
sumed, and with the same results as at first. In another family in which 
there were three children, all of whom had been taking syrup of ipecacu- 
anha and carbonate of potash for some days, without any good effects, 
the alum was given and acted as in the case first referred to. The nights 
were comparatively quiet, and the spells occurring through the day very 
much moderated. We may repeat that, so far as our experience in the 
above 139 cases goes, the effects of alum have been more decided and 
satisfactory than those of any other remedy. We have never known it to 
produce ill consequences, either at the time of its administration or sub- 
sequently, though we have given it to children from two months to seven 
years of age, and have continued its use from one to six weeks at a time. 
It, like all other remedies, sometimes fails, however, to do any good, and 
when we have found this to be the case, we have substituted belladonna 
or carbonate of potash, either alone or combined, and it is curious to ob- 
serve how, in some instances, the latter remedies will succeed where the 
other fails. Nothing but a trial will show which is the most proper in 
any individual case. Of late years we have usually given the alum and 
belladonna together, and have been much pleased with the results. If 
administered in large doses, alum produces vomiting. It does not con- 
stipate, but on the contrary, is apt to induce diarrhoea, when continued 
for some time. Dr. Bird gives from two to six grains every four hours. 
His formula is as follows : 

R. — Aluminis, . . . . . . . gr. xxv. 

Ext. Conii, ....... gr. xij. 

Syrup. Bhceados, fgij. 

Aquse Anethi, f gilj. — M. 

Give a medium-sized spoonful every three hours. 

To children under one year, we give from half a grain to a grain, 
three or four times a day; and to those over that age, two grains every 
four or six hours. The formula we have employed is the following: 

R. — Aluminis, 9ljss. 

Syrup. Zingib., Syrup. Acacige, Aquae Eontis, aa, f^j. — M. 

When this is prepared with good syrups, it tastes very much like lemon- 
ade, and is not at all unpleasant, so that children take it without diffi- 
culty. The dose is a teaspoonful three times a day, or every four or six 
hours. 

As above said, however, we now generally employ a combination of 
alum and belladonna, and have obtained better results from it than from 
any single remedy we have ever used. For a child one 3^ear old we use 
the following formula : 

R. — Ext. Belladonna, g r -j- 

Aluminis, ....... gss. 

Syr. Zingib., Syr. Acacise, Aquas, aa, . . 13J. 
M. et ft. sol. 
Dose, a teaspoonful four times in the twenty-four hours: in the morning, at noon, 
bedtime, and once in the night, if the cough be troublesome. 



246 HOOPING-COUGH. 

Among other remedies which have been highly recommended, but 
which we have never found it necessary to resort to, may be mentioned 
the following: 

Sulphur is much used by some German authorities, who greatly com- 
mend its effects both at the beginning and throughout the course of the 
disease. It may be given in powder diffused in milk or syrup, or in 
emulsion, in doses of three grains, two or three times a day, to children 
from two to four years of age. 

Subcarbonate of Iron has been successfully employed by Dr. Steyman, 
and by Lombard, of Geneva. 

Dilute Nitric Acid, first recommended by Arnoldi, of Montreal, has 
been highty praised, especially by Gibb. 

Goniuin has also been frequently used, both alone and as an ingredient 
in formulas containing some of the other remedies here mentioned, and 
appears to alleviate the violence of the paroxysms, though to a less 
marked degree, we believe, than belladonna. 

Finally, of late years the Bromide of Ammonium has been recom- 
mended, especially by Gibb and G. Harley, as a phaiyngeal and laryn- 
geal anaesthetic, to diminish the spasm of these parts, while, at the same 
time, the alkali acts by rendering the secretion from the bronchial mu- 
cous membrane more free and readily expectorated. The Bromide of 
Potassium acts in the same way, and is productive, probably, of equally 
good results. 

Inhalations. — It was noticed in France, some years ago, that children 
suffering with hooping-cough, who lived in the neighborhood of gas-works, 
were rapidly cured; and the plan has been recently tried with success, of 
sending patients with this disease to inhale the fumes arising during the 
purification of gas, which contain ammonia, vapor of tar, and several 
volatile oils. Dr. Bertolles (British lied. Jour., Nov. 5, 1864) states, that 
"the register of the gas-works at Ternes, shows that during the previous 
six months, 901 patients have been subjected to the vapor treatment, of 
whom 219 were cured and 122 relieved." M. Commerege (id. loc.) has 
also reported the effects observed in 142 children who were brought under 
the action of the gases in the gas-works at St. Maude ; and believes that 
the treatment produces excellent results at all stages of the disorder. In 
general, twelve seances, each of which should be of two hours' duration, 
are required for the cure. We have ourselves known of quite a number of 
instances among the children of the poorer classes in this cn^y, where pa- 
tients, suffering with hooping-cough, have been allowed to inhale the 
fumes from the gas-works, and have experienced positive benefit. 

Local Applications. — Revulsives. — The milder revulsives are useful 
in certain complications of pertussis, and as palliatives. To make them 
the chief basis of the treatment, however, which has been done by some, 
is a mistake. In order to produce a decided impression upon the disease, 
it would be necessary to resort to the more powerful remedies of this class, 
such as moxas, issues, tartar emetic ointment, blisters, &c, the use of 
which is not warranted by the nature of the disorder. 

When the laryngismus has been severe, we have known the use of a 



TOPICAL APPLICATIONS — TONICS. 247 

belladonna plaster, 2 by 3 inches, applied over the larynx and worn for 
several days, to afford relief. 

Topical applications to the interior of the larynx of solutions of nitrate 
of silver have been used by several practitioners, as b}^ Gibb and Eben 
Watson, and apparently with much benefit. The strength of the solution 
should vary according to the stage of the disease, being much reduced 
during the early acute period. 

Tonics. — In a number of cases that have come under our notice, the 
patient has grown pale and weak in the course of the disease, and this 
without any local complication, but from the disturbance of the digestive 
system that often exists to a greater or less extent, from the great fre- 
quency of the vomiting, which prevents them from taking a sufficient 
amount of nutriment, and from the exhausting effect of the violent mus- 
cular exertion undergone during the paroxj^sms. In such instances, when 
there has been no fever, or merely a little evening febricula, we have em- 
ployed tonics with much advantage, and never to the injury of the patient. 
"We have generally made use of Huxham's tincture of bark, either alone, 
in doses of from ten to twenty drops three times a day, or in connection 
with the syrup of the iodide of iron, or half a grain of the metallic iron 
(Pulv. Ferri). When the appetite has been very feeble, we have found 
that quinine, in the dose of a grain three or four times a day, at the age 
of three or four j^ears, has restored it more rapidly than any remedy we 
have made use of. 

Before concluding our remarks upon the treatment of simple hooping- 
cough, we wish to state that cases of the disease occur not unfrequently 
of so mild a form, as to need absolutely no treatment other than the 
proper degree of attention to hygiene ; and that others again, more numer- 
ous than those just mentioned, will be met with, in which the only treat- 
ment necessary is the use, for a few days or weeks, of some mild expec- 
torant and opiate at night to lessen the severity of the paroxysms, or of 
moderate doses of alum, belladonna, or carbonate of potash. 

In infants particularly it is proper to give as little medicine as possible, 
allowing the disease to go on without interference so long as it progresses 
safely. In a good many mild cases, small doses of paregoric and syrup 
of ipecacuanha, constitute the only remedies we have found necessary in 
the cases of infants. When, however, the paroxysms become numerous 
and violent, exhausting the strength of the child and distressing its ner- 
vous system, we must make use of some remedy to allay the severity of 
the attacks. We have found the alum and belladonna formula recom- 
mended above safe and effectual. At the age of two and three months, 
we have usually given from half a grain to a grain of the former, com- 
bined with ^ ? th grain of extract of belladonna, three times a da} r , taking- 
care to suspend it for a day or two if it caused troublesome vomiting 
or purging, and then resuming it in diminished dose. Or we have made 
use of a quarter or half a grain of carbonate of potash, also combined with 
the twenty-fourth part of a grain of the extract of belladonna, three or 
four times a day. 

Treatment of the Complications. — If any of the diseases which 



248 HOOPING-COUGH. 

have been mentioned as apt to occur during pertussis should arise, the 
treatment which is proper for them in their idiopathic form must be 
adopted without regard to the hooping-cough, with the following reserva- 
tion : that care must be taken not to use means of too powerful and ex- 
hausting a nature, or such as have a tendency to irritate the organs with 
with which the} r come in contact. For, it must be recollected, that after 
the complication is cured, the patient has still the original disease to go 
through with, and therefore requires all his strength ; and, moreover, the 
various organs of the body are predisposed, by the very fact of the exist- 
ence of the original malady, to assume diseased action, should any irrita- 
tion in the shape of a violent remedy be applied to them. 

The cases of bronchitis which came under our observation were treated 
in the simplest manner. The children were put to bed, the diet carefully 
regulated, the bowels gentry opened with castor-oil or syrup of rhubarb, 
and small doses of sj^rup of ipecacuanha or antimonial wine, with sweet 
spirits of nitre, were administered every two hours. Mustard poultices 
were applied once or twice a day to the interscapular space, and mustard 
foot-baths used every night, or more frequently, if the dyspnoea were con- 
siderable. If the bronchial secretions were very profuse, and the cough 
troublesome, the decoction or syrup of seneka was given in connection 
with occasional doses of laudanum or paregoric. 

The treatment of collapse should be that which is recommended in the 
article on collapse, modified, of course, as may be rendered necessaiy, by 
the existence of the hooping-cough. A mild emetic, if the patient seem 
strong enough to bear one ; counter-irritants, and especially sinapisms 
or mustard poultices applied to the chest, nutritious food, and mild stimu- 
lants, as brandy, wme-whe}^, tincture of bark, quinine, or aromatic spirits 
of ammonia, must form the principal means of treatment. 

The complication of pneumonia should be treated somewhat differently. 
In the 5 cases we have met with, the treatment employed consisted in the 
administration of small doses of antimonial wine and spirit of nitrous 
ether, and of Dover's powder, and in the use of the foot-bath ; and, in ad- 
dition, one, the eldest, was bled at the arm, and three others were leeched 
upon the chest ; they all recovered. At the present time we should advise 
the use either of the combination of sulphurated antimony and Dover's 
powder, or of one of the alkaline mixtures, recommended in the article 
on pneumonia, in conjunction with external applications and the use of 
the foot-bath ; and should not resort to bleeding, whether local or general, 
unless the indications, elsewhere laid down as calling for depletion in 
pneumonia, should be present in a marked degree. 

When convulsions occur they must be treated according to the cause 
which produces them, and the constitution and present state of the child. 
If the patient be strong and sanguine, and not exhausted by previous 
sickness, the treatment should consist of depletion by leeches to the tem- 
ples, or behind the ears ; of cold applications to the head ; the warm bath; 
cathartics or purgative enemata ; and revulsives in the form of sinapisms, 
or of a small blister to the nucha. If, on the contrary, the patient is of 
delicate constitution, or exhausted b}^ long illness, and especially when 



TREATMENT OF THE COMPLICATIONS. 249 

the convulsions are the result of extensive collapse of the lungs, occurring 
spontaneously or supervening upon bronchitis, we must be content to 
resort to warm baths, revulsives, antispasmodics and anodynes, stimuli, 
and stimulating enemata. 

Of the 12 cases of convulsions that came under our notice, 5 proved 
fatal. Two of the fatal cases occurred in children who had long been 
laboring under bronchitis, probably associated with collapse, that had 
baffled all treatment. Death took place within twentj^-four hours from 
the appearance of the convulsions, which were in fact the result of the 
diseased condition of the lungs. No treatment further than the warm 
bath and sinapisms, was resorted to. In the third case, the convulsions 
came on in the seventh week of the disease, in a child who had been labor- 
iug for a number of days under severe bronchitis ; they ended fatally in 
seven hours. The treatment employed at the beginning of the fit was a 
warm bath, an enema, and mustard plasters. After a few hours, solution 
of morphia with fluid extract of valerian were given by enema, cold was 
applied to the head, and a blister to the nucha. In the fourth case, which 
occurred in a child in the second yeat of its life, they were caused by 
bronchitis and collapse, and proved fatal in two days. The treatment 
consisted in the use of warm baths, counter-irritants, alum, and small 
doses of brandy. The fifth case likewise occurred in the second year. 
This was one in which all the symptoms of laryngismus stridulus, — pro- 
longed laryngismus, contracture, and general convulsions, — were added 
to those of the primary disease. It was treated with belladonna, opium, 
assafcetida, and warm baths, but all to no effect. 

Of the favorable cases, one occurred in a boy five months of age, on the 
third day of a severe attack of bronchitis. The child was immediately 
placed in a warm bath, and large sinapisms applied over the front of the 
chest and upon the extremities, when the convulsions ceased. After this 
he was treated with half-grain doses of alum, repeated every three or four 
hours, mustard foot-baths and poultices, and small doses of wine of opium. 
On the sixth day of the attack, the third after the convulsive seizure, 
there having been no return of the convulsions, the bronchitis subsided 
with copious sweats and cold hands and feet, for which small quantities 
of brandy and water and wine-whey were used. The recovery was per- 
fect. A second case occurred in a hearty boy nine months old, and seemed 
to depend on congestion of the brain, brought on by a severe fit of cough- 
ing. In this instance a venesection to a small amount was performed, 
the child was placed in a warm bath, and cold applied to the head. JS T o 
return of the spasms took place, and the child recovered without diffi- 
culty. In another case the convulsion was caused by an attack of fever 
depending on dentition, and was treated by lancing the gums, by a warm 
foot-bath, and by the administration of a grain of calomel in a teaspoonful 
of castor oil. In the fourth case the convulsions were caused hy pneu- 
monia, and were managed by treating the pneumonia, except that at the 
moment of the attack a warm bath and a stimulating enema were made 
use of. In a fifth the convulsion, which was a short one, occurred at the 
onset of an attack of bronchitis. No particular treatment beyond what 



250 HOOPING-COUGH. 

was necessary for that disease was required. In a sixth, in a bo}^ nine 
months old, the convulsion occurred suddenly, was violent, and lasted 
fifteen minutes. The cause could not be ascertained. The only treat- 
ment used for the convulsion was a warm bath. There was no return. 
In a seventh case, in a boy nine months old, a slight convulsion occur- 
red during one of the paroxj-sms in the fifth week. No treatment was 
necessaiw, as the attack was very short, and there was do recurrence of 
the S3 T mptoms. 

Hygienic Treatment. — This part of the management of the disease is 
of the highest importance, for it is by careful attention to its details, that 
the complications which constitute the chief danger of the malady are to 
be prevented. In a considerable number of cases of pertussis, nothing 
more need be done than to insist upon strict atteution to hygienic rules. 
The chief indications are, to preserve the child from taking cold, and to 
prevent indiscretions in diet. The clothing ought to be warm, and during 
the autumn, winter, and spring, flannel should always be placed next to 
the skin. The child ought to be kept in the house during damp weather 
at all seasons, and whenever, during the winter season, it is intensely 
cold. The diet should be nutritious, but of eas}^ digestion. All heavy, 
rich food ought to be absolutely forbidden during the continuance of the 
malad}'. 

Treatment of the Paroxysm. — It often happens that the paroxysms 
are so violent, that the child seems to be in imminent danger of suffoca- 
tion or of convulsions. This is especially true of infants. In six cases 
that we have seen, in infants under six months old, the kinks lasted so long, 
and the spasm of the laiynx was so unyielding, that the children strug- 
gled as though laboring under tetanus ; the countenance was disturbed 
and anxious ; the face and hands, at first flushed, became purple from 
deep congestion; and on some occasions the breathing was suspended for 
several seconds, so that life seemed for the time in the greatest danger. The 
difficulty in these cases depends on the spasmodic closure of the glottis, 
which is, sometimes, no doubt, completely shut. We have never known 
these alarming symptoms of asphyxia to occur when the hoop has been 
clear and distinct, for when that is present, the larynx cannot be very 
tightly closed. 

When the symptoms above described occur in a child several years of 
age, the patient should be raised and supported in the sitting posture ; 
when in an infant, the child ought to be held lightly in the arms, so that 
it ma} r take any position which instinct prompts it to. At the same time 
cold water ought to be sprinkled from the fingers upon the face, the child 
should be gently fanned, or, if the weather be warm, taken to the open 
window ; and if there be time, it is well to put the feet into mustard-water. 
It has been recommended on such occasions to apply compresses dipped 
into cold water to the sternum. We would propose the trial of a means 
which the late Dr. C. D. Meigs found very successful in arresting tonic 
spasm of the respiratory muscles, in a case of laiyngismus stridulus. This 
is the sudden application of a piece of ice wrapped in linen to the epigas- 
trium. When the laiyngeal spasm is very intense and obstinate, a bella- 



TREATMENT OF THE PAROXYSM. 251 

donna plaster, as before recommended, or a small blister to the front of 
the neck, rnay be useful in controlling it. 

M. Bell speaks very highly of the results obtained by sprinkling a lit- 
tle ether on the clothes of the patient at the onset of the paroxysm ; and 
Dr. Churchill (Diseases of Childhood, p. 223), who has tried ether in 12 
or 14 cases, and chloroform in 6, regards it as a valuable addition to our 
remedies. He directs that about half a drachm of sulphuric ether should 
be spilled on the nurse's hand and held before the child's nose and mouth 
at the commencement of a fit of coughing. In onty one or two cases no 
benefit accrued, while in others great mitigation of the spasm, and in three 
or four almost complete relief followed when the ether was thus applied. 
We should certainly recommend a trial of this procedure, making use, 
however, from preference, exclusively of the sulphuric ether. 



CLASS II. 

DISEASES OF THE CIRCULATORY ORGANS 



ARTICLE I. 

CYANOSIS. 

Synonymes. — Definition. — This peculiar condition, known under the 
various names of Morbus Coeruleus or the blue disease, and Cyanosis, 
may be defined as a permanent state of lividity or blueness of the skin, 
depending upon numerous malformations or derangements of the heart 
and great vessels. 

In a comparatively slight degree, this condition attends man}-- of the 
chronic organic diseases of the circulatory organs ; and is also transiently 
present in the course of some acute diseases ; but under neither of these 
circumstances does the lividity merit consideration as a separate affec- 
tion, being merely due to the imperfect ox^ygenation of the blood. 

There is, however, one form of cj^anosis which we have occasionally 
met with that merits a special reference. In these cases, the blueness of 
surface has appeared from three or four days to as many weeks after 
birth, has been intense in its degree, and associated with marked dis- 
turbance of respiration, and yet, under proper treatment, the infants 
have usually recovered. We believe that the cause of such cyanosis is to 
be found in atelectasis of the lungs, which acts partly by causing general 
venous congestion, and partly perhaps by obstructing the flow of blood 
through the pulmonary artery, so that the right cavities of the heart 
become distended, and there results an admixture of venous and arterial 
blood through the still unclosed foramen ovale. 

Before attempting to explain the peculiar blue color in cases of true 
cyanosis, it will be convenient to allude to the various lesions which have 
been found present in such cases. 

Morbid Anatomy. — The blood in cj^anosis is dark, and contains an 
excess of carbonic acid ; it has also lost to a great extent its coagulabilit} T . 
The only organs beside those of circulation which present lesions, with 
anj r constanc3 r , are the lungs. 

Dr. J. Lewis Smith (Bis. of Infancy and Childhood, 1869, pp. 578-599), 
who has studied this disease with great care, and collected all the cases 
of it upon record, finds the condition of the lungs recorded with more 
or less minuteness in 110 out of 191 cases. In 26 cases there was tubercu- 



CYANOSIS — MORBID ANATOMY. 253 

losis. either confined to the lungs, or chiefly exhibited in these organs; in 
35 cases the lungs were of small size, either from compression by effusion 
in the pleural sacs or pericardium, or sometimes, apparently, from the 
persistence of the foetal state over a greater or less portion of the organ. 
In 35 cases the lungs presented a dark color, owing either to- atelectasis 
or to engorgement and congestion. In 9 there was emphysema in a part 
of the lungs; in 2, pneumonia; in 2, the color was pale; in 1 a bright 
crimson ; in 1 the lungs were larger than natural ; in 1 the right lung 
was absent, and in 17 these organs were recorded as healthy. 

There is also found, in a large proportion of cases, venous congestion 
of the brain, liver, or kidneys. By far the most marked and important 
lesions, however, are those of the heart and great vessels, which are, 
excepting in extremely rare instances, the essential seat of the disease. 
The number of these lesions already recorded is considerable, as will be 
seen from the subjoined table borrowed from Smith, which shows their 
character and relative frequency. 

1. Pulmonary artery absent, rudimentary, impervious, or partially 

obstructed, 97 

2. Eight auriculo-ventricular orifice impervious or contracted, . 5 

3. Orifice of the pulmonary artery and the right auriculo-ventricu- 

lar aperture impervious or contracted, 6 

4. Eight ventricle divided into two cavities by a supernumerary 

septum, ........... 11 

•5. One auricle and one ventricle, ....... 12 

6. Two auricles and one ventricle, 4 

7. A single auriculo-ventricular opening; interauricular and inter- 

ventricular septa incomplete, ....... 1 

8. Mitral orifice closed or contracted, ...... 3 

9. Aorta absent, rudimentary, impervious, or partially obstructed, 3 

10. Aortic and the left auriculo-ventricular orifices impervious or 

contracted, . . . . . . . . . .1 

11. Aorta and pulmonary artery transposed, . . . . .14 

12. The cavae entering the left auricle, ...... 1 

13. Pulmonary veins opening into the right auricle, or into the 

cavse or azygos veins, ......... 2 

14. Aorta impervious or contracted above its point of union with 

the ductus arteriosus; pulmonary artery wholly or in part 
supplying blood to the descending aorta through the ductus 
arteriosus, 2 

162 

It is evident from a glance at this table, that the vast majority of the 
above lesions must occur before the full development of the heart is 
attained ; and that consequently, in nearly every instance, cyanosis is a 
congenital affection. But further than this it will be observed, that 
in the first four groups in Smith's table, or in 119 out of 162 cases, 
the lesions affect the right side of the heart, and are precisely of the kind 
that we know are caused by inflammation of the endocardium. Bearing in 
mind then the well-ascertained law, that endocarditis occurring during 
fcetal life, almost exclusively attacks the right side of the heart, we can 



254 CYANOSIS. 

readily understand how such lesions could be produced by an attack of 
inflammation affecting either the valves of the pulmonary artery, or the 
tricuspid valves, or some part of the lining membrane of the right ven- 
tricle. Should such an attack of endocarditis occur after the develop- 
ment of the cavities and septa of the heart, and the closure of the foramen 
ovale and ductus arteriosus, and lead to occlusion of the orifice of the 
pulmonary artery, it would of course be impossible for life to be sus- 
tained. But where such a lesion is produced, while the interauricular and 
interventricular septa are still imperfect, and the ductus arteriosus pat- 
ulous, so much compensation may be effected that life can often be pro- 
longed for many j^ears. Thus, it is evident, that the first effect of the 
closure of the orifice of the pulmonary artery, at such an early period, 
will be to cause a large portion of the blood from the right ventricle to 
pass directly through the opening remaining in the interventricular sep- 
tum into the left ventricle. Usually this opening is not free enough to 
relieve the right ventricle entirely, and there is consequently pressure ex- 
erted backwards on the blood entering from the right auricle, which forces 
part of it through the foramen ovale into the left auricle, and thus still 
further relieves the fulness of the right cavities. As there is no outward 
current through the pulmonaiy artery, owing to the occlusion of its ori- 
fice, blood flows back into this vessel from the aorta through the patulous 
ductus arteriosus, and thus supplies the lungs. At the same time the 
bronchial arteries become much enlarged, and, in some rare cases, blood 
has been able to reach the lungs through abnormal branches from the 
internal mammary or intercostal arteries. In cases of c} T anosis which 
prove fatal very soon after birth, the most' diverse and inexplicable lesions, 
as above enumerated, may be found ; but in those instances where life is 
prolonged, the heart is usually found to present the associated lesions 
above described : contraction or occlusion of the orifice of the pulmonary 
artery, imperfect interventricular septum, and patulous foramen ovale and 
ductus arteriosus. In such cases, when the compensatory communications 
between the right and left side of the circulation are free, life may be pro- 
longed for many years. 

This was very nearly the condition found in the following case, 1 the 
opportunity of examining and describing which we owe to the courtesy 
of Dr. C. H. Thomas. 

" The patient was a young man, set. 22 years, who had been markedly 
cj^anotic from infancy, and was poorly developed. He was unable to 
maintain a proper temperature. He suffered constantly from slight dysp- 
noea, with occasional exacerbations. At the autopsy there was marked 
congestion of the abdominal viscera, and the gall-bladder was packed 
with gall-stones. Both lungs contained numerous yellow miliary tu- 
bercles. 

" The heart was rounded. The cavities of the ventricles were not much 
enlarged, nor was there any hypertrophy of the walls of the left ventricle. 

1 See Descriptive Catalogue of Path. Museum of Penna. Hosp., No. 1501, p. 84, 
by William Pepper, M.D. 1869. 



MORBID ANATOMY — ILLUSTRATIVE CASES. 255 

The walls of the right ventricle were, however, decidedly thickened, thongh 
not equalling those of the left. The septum ventriculorum was dispropor- 
tionably thick, and terminated about one-third of an inch below the level of 
the origin of the aorta in a smooth, rounded edge, over which the endo- 
cardium was thickened. The septum also seemed inside of .its normal 
position, so as almost to bisect the aortic orifice. The aorta, which was 
slightly dilated but quite healthy, thus communicated freely with both 
ventricles. The origin of the pulmonary artery was very much obstructed, 
owing to coalescence and contraction of its valves. The ductus arteri- 
osus was, unfortunately, not preserved, but, owing to the large size of 
the pulmonary artery beyond the seat of obstruction, it had in all prob- 
abilit}' remained patulous. The foramen ovale was closed." 

In this instance, the orifice of the pulmonary artery not being entirely 
closed, the opening in the interventricular septum had been large enough 
to allow the right ventricle to relieve itself in that way, and consequently 
the foramen ovale had closed. 

The mere persistence of the foramen ovale can scarcely be regarded as 
a cause of permanent cyanosis. It is quite possible that during the early 
days of extra-uterine life, a certain amount of cyanosis might exist owing 
to the admixture of venous and arterial blood allowed by this opening, 
but after the forces of the circulation become equalized, it is quite cer- 
tain that the valve of the foramen may remain unattached, or may even 
be somewhat insufficient to close the opening, and yet no cyanosis be 
present. 

As an illustrative case of one of the rarer forms of cyanosis, and one 
which bears in the most interesting manner upon the theoiy of its pro- 
duction, we abstract the following from a more full account published in 
the Proceedings of the Pathological Society of Philadelphia. 1 

The child was a well-developed male, born at full term. No discolora- 
tion was noticed at birth, but on the twelfth day, as the grandmother was 
preparing to wash it, it had a convulsion, and from that time presented 
coldness of the extremities, gradually increasing lividity, feeble and rapid 
pulse, and moaning and sighing respiration. 

During inspiration, the sternum and upper parts of the chest were ele- 
vated, but the lateral regions remained unexpanded, and there was marked 
recession of the base of the thorax. The percussion-resonance was dimin- 
ished on both sides, but especially on the right. The vesicular murmur 
was puerile, except over the right side, where it was feeble. The cardiac 
sounds were decidedly louder at the right scapula than over the left. The 
cardiac impulse at the left nipple was very indistinct, and the sounds 
there feeble but natural. On pressing two fingers lightly to the left of 
the ensiform cartilage, close to the costal cartilages, a very distinct and 
quite vigorous impulse could be felt, one much more distinct than at the 
nipple. At this point a distinct blowing sound attended the systole of 

1 Transposition of the Arteries. Dr. J. P. Meigs. Proc. of Path. Soc, vol. ii, p. 
37 ; and Am. Jour, of Med. Sciences, vol. xi, 18G0, p. 415. 



256 CYANOSIS. 

the heart. The diagnosis made at the time was : atelectasis of both lungs, 
of the right greater than of the left ; dilatation with hypertrophy of the 
right ventricle ; obstruction of the pulmonary artery, and open foramen 
ovale. Death occurred on the forty-fourth da}^ after birth. 

At the autopsy, the body was very small and thin. The thorax was 
flattened laterally, and contracted at the base. There was marked collapse 
of the lower lobes of both lungs, and especially of the right. The heart was 
one-half too large, and fall, rounded, and distended with soft black clots. 
The walls of the right ventricle were very thick, and its cavity quite small ; 
it presented the appearance we usually associate with the left ventricle. 
The walls of the left ventricle were thinner than those of the right ; and 
its cavity was much more capacious than that of the right. The right 
auricle was dilated and considerably larger than the left. The foramen 
ovale presented an opening at its lower aspect of about 2 or 3 lines in 
diameter. The orifices of the venae cavse appeared smaller than usual. 

The aorta and pulmonary artery were transposed. The aorta arose 
from the right ventricle in the usual position of the pulmonary arteiy ; 
the pulmonary artery arose from the left ventricle, and passing under the 
arch of the aorta, gave to the latter, just beyond the left subclavian, the 
ductus arteriosus, which was quite pervious and of considerable size. The 
valves of the heart were healthy and not transposed. The pulmonary 
artery was of the natural size ; and presented no obstruction at its point 
of origin. After giving off to the aorta the ductus arteriosus, it divided 
as usual into two pulmonary branches, which soon subdivided into others. 

The aorta was of full size and presented nothing unusual. It gave off 
at its arch the innominate artery, and then the left primitive carotid and 
the left subclavian. Just beyond the latter it received, from the pulmon- 
aiy artery, the ductus arteriosus. 

The pericardium was normal in all respects. 

Theories as to the Production of Cyanosis. — In the vast majority of 
cases the malformation which causes cyanosis is of such a character as 
to allow admixture of the venous and arterial blood, and, at the same 
time, to interfere more or less with the circulation of this mixed fluid. 
Ever since the time of Morgagni, authors upon this subject have been 
divided in opinion as to whether the coloration of the skin were due ex- 
clusively to one or the other of these causes ; obstruction to the cardiac 
circulation and consequent venous congestion, or intermingling of the 
venous and arterial blood. 

In regard to the first of these causes, although it has numbered among 
its advocates Morgagni, Louis, and Stille, it cannot be considered com- 
petent to fuUy explain all the cases and peculiarities of C3>-anosis, although 
such central obstruction will unquestionably aid in its production. 

Nor can the second theory be held exclusively sufficient, since not 
only are there cases met with where cyanosis is present and yet no ad- 
mixture of venous and arterial blood is possible, but also, on the other 
hand, where a considerable degree of admixture exists without the pro- 
duction of cyanosis. 



SYMPTOMS. 257 

It seems necessary therefore, as Smith has clearly pointed out, that any 
theory which pretends to embrace all the elements of this complex con- 
dition, should einbodj" a reference to the fact that the essential defect in 
cyanosis is a want of arterialization of the blood. 

Symptoms. — Even in cases where cyanosis is due to congenital organic 
lesions, the peculiar symptoms are not alwaj^s present until some time 
after birth. 

Thus, in 138 of the cases of cyanosis collected by Smith, the time at 
which lividity was first noticed is stated as follows : 

In 97 it was within the first week, and often within a few hours after birth. 

In 3 at 2 weeks. In 6 from 2 to 5 years. 

" 1 " 3 " "1 "5 » 10 " 
" 2 " 1 month. " 6 " 10 " 20 " 

" 7 from 1 to 2 months. " 1 << 20 " 40 " 

"5 " 2 " 6 " " 1 over 40 years. 
"5 " 6 " 12 " — 

"3 " 1 « 2 years. 41 

Dr. Smith adds, "that in these 41 cases, in which blueness did not 
occur till after the age of one week, if the patient were less than two 
years old when it commenced, there was frequently no obvious exciting 
cause ; but above this age, with three exceptions, such a cause is known 
to have been present. It is interesting to observe how trivial the exciting 
cause frequently is " (an acute attack of sickness, an attack of convul- 
sions, difficult parturition, a fall, or even a severe blow), " and equally 
interesting to note how long patients have enjoyed good health, not having 
the least lividity, although the anatomical vice, to which the final devel- 
opment of cyanosis was due, had existed from birth." 

The most characteristic symptom of cyanosis is the lividity of the sur- 
face, which varies in different cases from mere duskiness to a deep pur- 
plish tint. This color also varies in degree in different parts of the body, 
being most marked in the distant and especially the dependent portions, 
upon the mucous membranes, and wiierever the capillary vessels are 
abundant, as on the face. Its degree varies, finally, in the same case with 
the condition of the circulation. In slight cases, where the patient is 
quiet and the circulation tranquil, the discoloration of the surface may 
be imperceptible, but upon any exertion, and especially in the more severe 
cases, the lividity becomes much intensified. In some instances, such as 
that narrated by us below, there may be actual ecchy moses of the surface, 
as in purpura. 

The state of the general nutrition is much impaired, and the subjects 
of this disease are usually stunted and illy-developed. In many instances 
the generative system appears even more imperfectly developed than the 
rest of the economy. The temperature of the body is always reduced, 
and exposure to cold is very poorly borne. 

In a good many cases the thorax presents the deformity so often found 
in association with rickets, known as the u pigeon-breast." It usually 

17 



258 CYANOSIS. 

happens, also, that the ends of the fingers and toes become bulbous. Dis- 
turbances of the circulation and respiration are of frequent occurrence. 
Thus, there is often some abnormal bruit heard in the cardiac region, 
due to the abnormal condition of the heart. The pulse may be regular 
and of fair volume, but more frequently is small, irregular, or intermit- 
tent, and palpitation is very readily induced by exertion. The disturb- 
ance of respiration usually corresponds in degree with the embarrassment 
of the circulation. 

While the patient remains quiet his breathing may be easy and regu- 
lar, but usually any sudden movement or exertion or emotion is sufficient 
to induce a paroxysm of dyspnoea, during which the lividity of surface 
becomes much deeper. In infants these paroxj^sms not rarely terminate 
in convulsions. Headache is frequently complained of, and is very apt 
to be caused by whatever disorders the circulation. During the paroxj^sms 
of palpitation, pain is often complained of in the region of the heart, but 
is rarely persistent. 

Owing to the extreme venous stasis frequently present, there is a 
tendency to passive hemorrhages in cj^anosis, which expresses itself by 
bleeding from the nose, mouth, stomach, or rectum, or under the skin. 
(Edema of the lower extremities is often met with as a temporary con- 
dition after long standing on the feet ; it is also apt to appear and to 
invade the rest of the body towards the close of the case, when the cir- 
culation becomes more enfeebled. 

Modes of Death. — Many cyanotic patients die from the effects of 
some intercurrent acute disease, as hooping-cough or one of the exan- 
themata, all of which are very badly borne in this condition. 

The theory that venous congestion is opposed to the development of 
tuberculosis, was applied by Rokitansky to this affection ; but without 
any sufficient ground, since, as we have seen already, tuberculosis was 
found as the cause of death in no less than 26 of the cases collected by 
Dr. Smith. 

In other cases death occurs suddenly, either during an attack of con- 
vulsions or a paroxysm of dyspnoea. 

In severe cases of C} T anosis life is rarely prolonged more than a few 
years ; but in less marked cases the patients ma}^ even attain middle age. 
In 186 cases collected by Dr. Smith, the age at death was as follows : 



In 17 under age of 1 week. In 21 from 5 years to 10 years. 

" 10 from 1 week to 1 month. "41 « 10 » "20 " 

« 12 " 1 month to 3 months. " 20 " 20 " " 40 " 

" 11 " 8 months to 6 months. " 4 over 40 years. 

<< 17 " 6 " to 12 " 

" 12 " 1 year to 2 years. 186 
" 21 " 2 years to 5 " 

So that in 6*7, or more than one-third, death occurred before the close 
of the first year; in 121, or more than three-fifths, before the age of 10 
years; only 24 survived the age of 20 years, and 4 the age of 40 years. 



TREATMENT. 259 

TTe subjoin the history of a case of cyanosis which we have had under 
observation for several } T ears, in which the symptoms of this peculiar con- 
dition are extremely well marked. 

J. W., set. 1G years and 7 months, has been cyanotic since infancy, but 
for the past few years, at least, has enjoyed fair health. At present there 
is marked lividity of the lips and of the nose, especially at the extremity, 
which seems somewhat increased in size. His hands habitually appear 
as though stained with solution of carmine, the skin being uniformly livid 
over the whole hands, but becoming lighter colored on forearms. Pressure 
partly removes the lividity, which returns slowly after the withdrawal of 
the pressure. At times there have been little ecclrymoses of the surface, 
followed by the effusion of serum under the epidermis, and the formation 
of superficial excoriations, which have left small cicatrices. Only a few 
of these have appeared on the hands. 

These vascular disturbances are even more marked in the lower ex- 
tremities. The feet are continually deeply livid ; and over their surface 
and the ankles, very numerous ecchymotic spots have appeared, which 
underwent the same changes as those on the hands, and have left shining 
cicatricial spots, of a deep blackish-red color, from the deposit of pigment, 
and surrounded b} T a dark brownish stain. There has also been a good 
.deal of oedema of the feet lately. All of these conditions have been im- 
proved b}^ the use of tight-laced stockings. The skin of both the hands 
and feet is rather soft and moist. The last phalanges, both of the fingers 
and toes, are markedly clavate and hypertrophied. Firm pressure upon 
them reduces their size; but, upon withdrawal of the pressure, the blood 
slowly returns, and they regain their former size. The temperature of the 
bod}' is alwaj's low, and he suffers extremely from exposure to cold. 

He suffers somewhat from cbyspnoea, even upon slight exertion, but less 
so than formerly. He is also troubled with cough during the winter 
months. There is marked deformnVy of the thorax, the first and second 
pieces of the sternum uniting at an obtuse angle, and the cartilages of the 
third, fourth, fifth, and sixth ribs, forming a marked prominence on either 
side of the sternum; the ensiform cartilage is considerably depressed. 

The apex-beat of the heart is in the fifth costal interspace, and just in- 
side of the vertical line of the nipple. The heart's action is regular, and 
at present there is no abnormal cardiac murmur, though two years ago 
there was a distinct soft systolic bruit. The pulse in the standing posture 
is 114, in the sitting, 108. He -has occasional attacks of epistaxis, and 
suffers quite frequently from attacks of gastric disturbance attended with 
severe headache. 

Treatment. — In the form of cyanosis which we have described as de- 
pending on collapse of the lungs, the child should be placed in the posi- 
tion below recommended as rendering the heart's action most free ; the 
temperature of the body should be carefully maintained, and a few doses 
of brandy in water or breast-milk should be given at intervals. There is 
evidently but little good that can be done by mere medication in cyanosis 
depending on malformations of the heart. When -the heart's action is 
feeble and irregular, digitalis, iron, and quinia, ma} r be administered. 



260 DISEASES OE THE HEART. 

During the paroxysms of palpitation and dyspnoea, the best remedies are 
diffusible stimulants, such as Hoffman's anocVyne, spirit of chloroform, 
ammonia, and brandy ; and derivatives, such as sinapisms to the chest 
or hot mustard foot-baths. In cases where the digestion is markedly 
feeble, the use of vegetable tonics is indicated. 

B} 7 far the most important part of the treatment however, is a strict at- 
tention to the lrygienic conditions of the patient. He should, so far as 
may be practicable, avoid all excitement and active exertion ; his diet 
should be digestible and nutritious, his clothing should be warm, and, in 
addition, he should carefully avoid all exposure to severe cold. 

In cases where the venous congestion of the legs is marked and attended 
with oedema or with enlargement of the veins, laced stockings should be 
worn. 

It occasionally happens that cyanotic patients find that certain posi- 
tions afford them peculiar ease and comfort. Believing that in cases 
where the lividity appeared soon after birth (c3 r anosis neonatorum), it 
was due to a patulous condition of the foramen ovale, the late Dr. 
Charles D. Meigs was led to recommend (Diseases of Children, 1850, p. 
92), that such children should be placed upon a pillow, on the right side, 
the head and trunk being inclined upwards about 30° or 45°. The object 
of this position was "to bring the septum of the auricles into a horizontal 
position, so that the blood in the left auricle might press the valve of 
Botalli down upon the foramen ovale." 

In a certain number of cases the adoption of this recommendation has 
undoubtedly seemed to relieve the lividity, so that it is perhaps desirable 
that all cyanotic infants should be placed in this position ; though from 
a glance at the anomalies in the formation of the heart which frequently 
attend C} T anosis, it is evident that in most cases it could furnish no mate- 
rial relief. We are ourselves inclined to attribute the relief afforded by 
this position, not to an} 7 influence upon the foramen ovale, but to the fact 
that the heart's action is far most free and unincumbered when the child is 
placed upon the right side, with the trunk somewhat elevated. 



ABTICLE II. 

DISEASES OF THE HEART. 

As we are prevented, by the limits of this work, from giving any de- 
tailed account of many of the affections which merely occur in childhood 
in common with adult life, we propose in this article to offer only a few 
practical remarks upon the differences presented by diseases of the heart 
occurring at these two periods of life. 

Apart from those congenital malformations of the heart, already dis- 
cussed in the preceding article, the diseases of this organ most frequently 
met with in childhood, are pericarditis, and acute and chronic endocar- 
ditis, with valvular disease. 



ACUTE PERICARDITIS. 261 

The most frequent causes of these affections are rheumatism, the pe- 
culiar alterations of the blood present in scarlatina, rubeola, and diph- 
theria, and extension of inflammation from the adjacent tissues, in cases 
of pleurisy or pneumonia. Of these well-recognized causes, rheuma- 
tism is by far the most frequent ; for, although young children are com- 
paratively rarely the subjects of this disease, it is followed by some car- 
diac complication in a larger proportion of cases in childhood than in 
after years. This fact will be more fully referred to in our remarks upon 
rheumatism, where we dwell upon the importance of recognizing this 
marked tendency, and of watching most critically for the appearance of 
any symptom indicating that the heart has become involved. This ex- 
treme watchfuluess is the more necessaiy, because it frequently happens 
in young children, that for several days before the development of any 
local articular trouble, there may exist marked rheumatic fever, with 
serious inflammation of the membranes of the heart. 

In a few instances an acute cardiac affection cannot be traced to any of 
the causes above-mentioned, but appears to occur idiopathically, without 
exposure to any recoguizable exciting cause. 

So, too, in some cases of chronic valvular disease, and especially, it has 
seemed to us, of contraction and thickening of the mitral valve, the lesion 
cannot even be traced to any acute attack of endocarditis, but seems more 
akin to a fibroid degeneration, whose cause and early symptoms have been 
obscure and entirely overlooked. 

Possibly, in some of these interesting cases, the real starting-point of 
the disease may have been an attack of endocarditis in foetal life, which 
partially spoiled the valve, and set on foot degenerative changes, which 
slowly increased until they produced fatal symptoms. 

Acute Pericarditis may occur at any period after birth. In very young 
infants it has been observed in conjunction with peritonitis, and was ap- 
parently due to erysipelas ; while in other cases no cause could be assigned 
for its occurrence. The symptoms are, however, so vague and difficult to 
appreciate at this tender age, that the lesion is rarely recognized until 
after death. The infant is evidently in pain ; the features are pinched 
and shrunken, the skin hot at first, and the pulse and respiration greatly 
accelerated. The physical signs can, however, rarely be satisfactorily 
determined, partly because death usually occurs before the lesions reach 
any considerable degree of development. 

In older children the plrysical signs are often obscured by the coexist- 
ence of some inflammatory condition of the lungs or pleura, and the ex- 
istence of pericarditis can only be surmised by the presence of a degree 
of disturbance of the circulation and respiration out of all proportion to 
the amount of lung trouble. 

When, however, pericarditis occurs without any such complication, it 
may be often recognized by the seat of pain ; the existence of great dysp- 
noea, amounting at times to orthopncea ; the great frequency of the pulse, 
which is often small, and even irregular; the disturbance of circulation, 
as shown by lividity of the lips and face; and, finally, by auscultation and 
percussion, which reveal at first merely a friction-sound, and later, when 



262 DISEASES OF THE HEART. 

effusion has occurred, distant and feeble heart-sounds, with an increased 
area of cardiac dulness. 

When severe, pericarditis in children usually proves fatal. After death 
the same anatomical lesions are found as after pericarditis in adult life. 
The membrane is, in the first stage, reddened, injected, dryish, and 
slightly roughened; while later it is still injected and even ecchymosed, 
thickened, softened, and covered with patches or uniform layers of whi- 
tish or yellowish-white lymph, the surfaces of which are usually flocculent 
or irregularly roughened. The pericardial sac contains a variable quan- 
tity of turbid, or, at times, bloody serum; or, in secondary cases, of sero- 
purulent fluid. 

In cases where recovery takes place, the results of the previous inflam- 
mation are found, after death has occurred from some other cause, in the 
form of more or less extensive adhesion of the two layers of the pericar- 
dium, or merely of thickening and opacity of that membrane. 

Treatment. — In idiopathic cases, if the disease be recognized in the 
early stage, we should advise local depletion over the prsecordia by three 
or four leeches, or cut-cups in a child of five j^ears of age, followed by the 
application of warm mush-poultices ; the depletion being repeated if indi- 
cated; the internal use of large doses of acetate of potash and iodide of 
potassium, and the careful administration of nutritious diet and small 
amounts of stimulus, if the powers of the circulation seem likely to 3 T ield 
to the influence of the disease. 

In the very rare instances where the disease becomes chronic, and the 
effusion remains unabsorbed, the treatment should consist in the repeated 
application of small blisters over the prsecordia, and the internal use of 
iodide of potassium, iodide of iron, with tonics and nutritious diet. 

Endocarditis. — In the majority of cases, acute endocarditis in children 
occurs in conjunction with pericarditis. It is due to the same series of 
causes, also, as have been alreacty enumerated wheu speaking of this latter 
disease. And as it is of far more frequent occurrence than pericarditis, 
and productive of even more serious results, it is necessary that we should, 
if possible, be more upon the alert to detect the very earliest symptoms 
of its presence. 

In severe cases, whether occurring idiopathicall} T , or as a complication, 
or sequel of some other disease, there is violent disturbance of the circula- 
tion, with great dyspnoea, and short, dry cough, without any of the phys- 
ical signs of pulmonary disease. The child is extremely restless, and, 
upon auscultation, an abnormal bruit is heard attending the heart's action. 

But more frequently the acute symptoms are not so marked or charac- 
teristic as this, and, when ensuing in the course of acute rheumatism, may 
consist merely in a little increase of the heat of the skin, frequency of 
the pulse and restlessness, with or without vague complaints of pain about 
the prsecordia. 

Absolutely the only waj' of recognizing such cases is by auscultation, 
and consequently we would urge the immense importance not only of 
carefully ausculting the heart daily, in every case of acute rheumatism in 
a child, but also in every case where anomalous febrile symptoms, with 



CHRONIC VALVULAR DISEASES. 263 

acceleration of pulse, are present, and particularly if there be general 
soreness, or even resistance to motion. 

In very severe attacks of acute endocarditis, death may occur early; 
but more commonly the disease is less severe, and the urgent symptoms 
subside, leaving, however, in but too many cases, organic valvular disease. 

When death occurs during the acute stage, the endocardium is found 
injected, reddened, softened and readily detached from the muscular wall. 
The lesions are most marked on the left side of the heart, and especially 
on the endocardium covering the mitral valve, where, in addition to the 
above-mentioned appearances, there are usually patches or rows of small 
vegetations. We have alluded at some length in our article on chorea, 
to the theory which has been framed to explain the frequent occurrence 
of this latter disease in connection with rheumatism, by the separation of 
minute fragments of such vegetations, and their impaction in some of the 
vessels of the brain. 

The treatment of acute endocarditis should be the same as that recom- 
mended for acute pericarditis. 

Chronic Valvular Diseases. — These arise, as in adult life, either from 
an acute attack of endocarditis, or from some slow alteration in the tissue 
of the valves. 

The anatomical changes which are ultimately found, do not appear to 
differ essentially in these different cases, and consist of thickening, con- 
traction, and coalescence of the valves and their chordae tendinese ; vegeta- 
tions or calcareous incrustations upon the valves ; and, as a consequence, 
contraction of the orifices of the heart, or on the other hand, insufficiency 
of the valves to close them. 

The size of the cavities and the thickness of their walls also undergo 
various changes ; the former usually "becoming dilated, while the walls 
either increase or diminish in thickness. 

The general sjanptoms during the early stages of chronic valvular dis- 
ease, are often extremely slight, consisting merely of some interference 
with the general development of the body ; a little palpitation of the heart, 
and ctyspncea on exertion ; occasional precordial distress, and perhaps 
slight prominence of the cardiac region. 

The vague character of these symptoms accounts for the fact that, after 
the subsidence of the acute symptoms of endocarditis, when the disease 
has begun in that way, such cases are very often neglected, and receive 
no proper care until the occurrence of dyspnoea, cough, and dropsy, gives 
warning only in time to recognize the approach of the fatal termination. 

We make these remarks especially to call attention to the insidious 
mode of approach of many cases of chronic valvular disease of the heart 
in children ; and to impress upon our readers the important practical 
rule that, whenever, in the investigation of a child suffering with obscure 
ill health, we learn of the previous occurrence of acute rheumatism, or 
find mentioned among the symptoms any irregularities of the circulation 
or action of the heart, careful physical exploration of the heart should 
immediately be practised. 

Later in the course of the case, when the powers of the heart have be- 



264 DISEASES OF THE HEART. 

gun to fail under the constant obstruction to the circulation, the whole 
train of painful s}nnptoms, so well known in connection with organic 
heart disease, make their appearance. 

The physical signs are at all times such as are present in cardiac dis- 
ease in adult life, the only points of difference being that, in children the 
abnormal murmurs are more frequently seated over the mitral valve and 
towards the apex, and that there is usually a much greater degree of 
prominence of the prsecordia. 

It is by no means in every case, however, that the disturbances of cir- 
culation progressively increase as the child grows older. 

Fortunately it often happens that when the lesion is not extensive, and 
when the patient is placed under favorable circumstances, the heart ac- 
commodates itself in its growth to the defective state of the valves, and 
overcomes the impediment to the circulation by acquiring increased pro- 
pulsive force. But not only are valvular lesions in childhood thus partly 
compensated by hypertrophy of the walls of the heart, but there is also 
an undoubted tendenej^ in favorable cases, for the valvular lesions them- 
selves to diminish. Thus in the list of cases, which we have appended 
to this brief article, there will be found several, where positive abnormal 
bruits, due to organic valvular disease, have gradually disappeared in the 
course of years. 

It is however only when the general nutrition of the patient is good, 
so that the tonicity of the heart's tissue is preserved ; and when all ex- 
posure and exertion, which could overtax the energies of the crippled 
organ, are carefully avoided, that such compensation and gradual re- 
covery are possible. 

For in cases where the vigor of the heart's action fails, and degenera- 
tive changes occur in its muscular tissue, the tonicity of the walls soon 
diminishes, and allows the development of passive dilatation of the cavi- 
ties. In this condition it is not long before the most grave symptoms of 
embarrassed circulation appear, and the case passes more or less rapidly 
through the stages common to fatal organic disease of the heart. 

In the management of such cases, the most important point to be at- 
tended to is the careful regulation of the mode of life. The child should 
be warmly clothed, and carefully protected from any exposure which might 
induce an attack of rheumatism ; all violent exertion of body or mind 
should also be avoided, and, so far as possible, all sudden emotions, as 
fright or anger. The diet should be nutritious and digestible, and if the 
appetite should fail, and the child appear weakly and pale, vegetable ton- 
ics, with iron, should be administered. 

In cases where the heart's action is excited or irregular, the prolonged 
use of digitalis is often followed by marked relief; and whenever severe 
parox}^sms of palpitation occur, they should be treated by antispasmodics, 
diffusible stimuli, and revulsives. 

Although the most powerful agencies in causing improvement appear 
to be time and general attention to Irygiene, we think we have noticed, 
especially in cases of rheumatic origin, decided advantage from a course 
of iodide of potassium. 



cases. 265 

TVe will conclude this brief sketch by giving a few cases, selected from 
those occurring in our practice, which will serve to illustrate the points 
to which attention has been especially directed. 

Case 1. Acute pericarditis. — M. M., a girl, set. 3 j^ears, was seen in con- 
sultation, suffering with what was supposed to be an attack of pneumonia. 
Death occurred soon, and there was found to be extensive acute peri- 
carditis, with effmsion of serum and lymph. 

Case 2. Fatal acute endocarditis. — 0. M., a girl, between 4 and 5 
years old, was seized with a violent attack of illness, attended with fever, 
cough, ch^spnoea, and a loud and rough sj^stolic murmur at apex. Death 
occurred at the end of four weeks, and at the autopsy, marked inflamma- 
tion of the mitral valves was found with abundant fringe-like vegetations 
on the leaflets. 

Case 3. Mitral contraction of obscure origin. — C, a girl, set. 5 j^ears, 
apparently in excellent health, and with no history of any acute illness. 
We detected by accident a loud, high-pitched, systolic murmur at the 
apex. Her parents removed from this city to New Haven where, five 
years later, she died suddenly. The mitral orifice was found much con- 
tracted and the left ventricle Irypertrophied. 

Case 4. Acute rheumatic endocarditis ; improvement, but persistent 
murmur. — A. N., a girl, at age of 9J years, had a violent attack of acute 
articular rheumatism with endocarditis. This was followed by a double 
murmur at aortic orifice, which continues«to the present time, though she 
has grown up, married and has one child. Her health is delicate, and 
she has very moderate dyspnoea on exertion. 

Case 5. Repeated attacks of chorea ; chronic valvular disease. — A.. C, 
a girl, at age of 8 years, had a very violent attack of chorea without 
any cardiac S3 T mptoms. At the age of 11 years, she had a second attack, 
during which there was developed a loud, rough and prolonged systolic 
murmur at the apex, which still persists at the age of 12 years. Her 
health is now quite good, though her face is pallid, the cardiac impulse 
strong, and she is somewhat short-breathed on exertion. 

Case 6. Acute articular rheumatism; endocarditis ; recovery ; mur- 
mur persistent but diminishing. — H. S., a boy, set. 12 years, had a severe 
attack of acute articular rheumatism in April, 1869, with swelling, red- 
ness, and pain of joints; a systolic murmur appeared at the apex without 
?my pericarditis. He recovered, under the use of alkalies and opium. 
In November, 1869, seven months after the attack, he seems perfectly 
well ; has no dyspnoea except on violent exertion. The murmur at the 
apex is still audible, but less marked than three months ago when he was 
last examined. 

Case 1. Repeated attacks of chorea ; chronic valvular disease. — Gr., 
a girl, had chorea twice, at the age of 8 and 12 years. During this last 
attack a diastolic aortic murmur was detected, which is still present at 
the age of It years. Her health is delicate; she is pale and weak, and 
suffers from dyspnoea on exertion. 

Case 8. Acute rheumatic endocarditis ; persistent murmur. — M. X., 
a girl, at the age of 10 years, had a violent, long-continued attack of 



266 DISEASES OF THE HEART. 

articular rheumatism, during which a regurgitant aortic murmur ap- 
peared, which is still persistent at the age of 17 } T ears, though her general 
health is very good, and she has no dyspnoea on ordinary exertion. 

Case 9. Acute endocarditis (rheumatic?); marked improvement in 
general symptoms, but persistent murmur. — B. H., a girl, at age of 4 years 
suffered from an ordinary catarrh, when we detected a loud, high-pitched 
murmur at the apex, and on inquiry, learned that, when 2J years old, 
she had a violent inflammation of the chest, supposed to be catarrhal fever. 
At present, at the age of 12 years, she is in excellent health, without any 
of the rational signs of cardiac trouble, but she still has a well-marked, 
rather prolonged, high-pitched, systolic murmur at the apex. 

Case 10. Repeated attacks of rheumatism with severe mitral disease ; 
improvement in general symptoms and force of the murmur. — L. S., a 
girl, was subject to attacks of rheumatism from very early age, and has pre- 
sented s}^mptoms of cardiac disease from infancy. At age of 13, there 
was a strong systolic murmur heard over base and toward apex. She 
suffered much from violent palpitation, pain in prsecorclia, headache, and 
habitual d3 T spncea, much increased on exertion. At age of 18, there is 
still a systolic mitral murmur, but of much less intensity than formerly. 
Her general health is excellent, and she has but little dyspnoea or palpi- 
tation at any time. The heart's action is still readily excited ; the impulse 
strong, but without thrill ; there is marked increase in the area of cardiac 
dulness, but no positive prominence of the prsscordia. 

Case 11. Acute rheumatic endocarditis, chronic mitral disease ; recov- 
ery in five years. — J?. R., a girl, at the age of 6 years, was attacked 
with slight rheumatic fever, without any articular sj^mptoms. In a few 
days, a distinct but not loud, rather low-pitched systolic murmur was 
heard at the apex. The treatment consisted of rest in bed, quinia, and 
Dover's powders. After ten days, all the acute symptoms disappeared, 
but the murmur continued. She regained her health, but for two 3'ears 
the murmur could be detected, but then gradually diminished ; and now, 
five 3 T ears after first attack, no murmur can be detected, the first sound 
at the apex being merely a little prolonged. Her general health is ex- 
cellent. 

Case 12. Acute rheumatic endocarditis ; valvular disease, gradually 
recovering in course of two years. — M. B., a girl, at the age of 7 years 
had fever of a type that made us suspect pneumonia or pleuris} T , but with- 
out cough, pain in the chest, or any of the physical signs of pulmonary 
disease. On the third da} T , there was complaint of pain in one groin, but 
with no other articular s3miptoms ; rheumatism being suspected, a careful 
examination detected a roughish sj'stolic murmur at the apex. She was 
leeched at the prsecordia, confined strictly to bed, and had Dover's powders 
given her. The fever subsided, but the murmur continued for two years, 
gradually growing faint and finally disappeared. 

The effect of exposure and exertion in inducing a fatal result in cases 
which otherwise might have gradually improved, is well shown in the 
following instance. 

Case 13. Repeated attacks of acute rheumatism in early childhood ; 



cases. 267 

valvular disease and hypertrophy ; gradual improvement; exposure to 
hardships of army life: rapid aggravation of symptoms and death. — W. 
D., male, as a young child suffered from repeated attacks of acute articu- 
lar rheumatism with cardiac complication. At the age of 9, Dr. Gerhard 
pronounced him to be suffering from valvular disease and hypertrophy 
of the heart. 

His condition was gradually improving, and he had so few S3 T mptoms 
of cardiac disease that, at the age of 18 years, he was able to enter the 
infantry service. At the end of one } T ear, however, he was discharged 
for disability, and when seen by us in July, 1864, presented the following 
symptoms : bulging of praecordia ; manked extension of the cardiac im- 
pulse, which was heaving and powerful ; marked increase in the area of 
cardiac dulness from the presence of pericardial effusion ; and strong 
systolic mitral murmur. He had lost flesh ; the surface was sallow and 
lips livid ; there was frequent cough with occasional haemoptysis and epis- 
taxis ; the liver was enlarged, and there was frequently oedema of the feet. 

Towards the close of the year, the heart's action grew more labored 
and feeble, the pulse thready and frequent, the entire body became ana- 
sarcous, and considerable ascites appeared. He suffered from constant 
orthopucea and frequent cough, with bloody expectoration. The skin of 
the legs subsequently became gangrenous in parts, and he died Decem- 
ber 28th. 

At the autopsy, the heart was found enormously enlarged, extending 
over to the right of the sternum. The pericardium was firmly adherent 
throughout its extent, and in places was J inch thick; there were several 
cartilaginoid plates in the substance of the investing pericardium. 

The heart measured 9J inches from apex to base, and 6 inches across 
at the base of the ventricles ; the walls of the left ventricle were 1 \ inches 
thick ; the auricles were enormously dilated with very thin walls. The 
aortic and pulmonary valves were healthy and apparently sufficient; the 
tricuspid valves were also healthy, but probably insufficient. The mitral 
valves had entirely disappeared, from shrivelling and contraction, and 
there merely remained a very thick fibrous ring, studded with calcareous 
masses, bounding the auriculo-ventricular opening. 

The muscular tissue of the heart presented an incipient state of fatty 
degeneration. 

The liver was enormously enlarged, reaching nearly to the umbilicus, 
and presented intense nutmeg congestion. 

The kidneys were large and congested, and the spleen three times its 
normal size. 



CLASS III. 

DISEASES OF THE DIGESTIVE ORGANS. 
CHAPTER I. 

DISEASES OF THE MOUTH AND THROAT. 

"We find ourselves much embarrassed as to what classification of the 
diseases of the mouth is the most proper to adopt. So much confusion 
reigns amongst authors as to the nature of these affections, and conse- 
quently as to their nomenclature, that it is very difficult to reconcile the 
various discrepancies which exist. After much consideration, however, 
we believe that the following: arrangement is the one best suited to the 
existing state of knowledge upon these affections : 

1. Simple or erythematous stomatitis. 

2. Follicular stomatitis, or aphthae. 

3. Ulcerative, or ulcero-membranous stomatitis. 

4. Gangrene of the mouth. 

5. Thrush, or stomatitis with curd-like exudation. 

6. Simple, or erythematous pharyngitis. 

It will be observed that the only disease of the throat of which we treat 
is simple or erythematous pharyngitis. In the previous editions of this 
work, we also described pseudo-membranous pharyngitis in this place, 
but further observation and research have clearly established the fact 
that this is but the local manifestation of a constitutional affection, diph- 
theria ; and we have accordingly given a full account of the whole sub- 
ject, under this latter name, in the section on constitutional diseases. 



ARTICLE I. 

SIMPLE OR ERYTHEMATOUS STOMATITIS. 

Definition; Frequency This form of stomatitis consists of simple 

diffuse inflammation of the mucous membrane of the mouth, unattended 
by vesicular or pustular productions, by ulcerations, or by membranous 
exudation. It is a disease of infrequent occurrence, except in the form- 



STOMATITIS — APHTHAE. 269 

ing stage of other kinds of stomatitis, and of little importance, seldom 
requiring the attention of the physician. 

The causes of the disease are the introduction of irritating substances, 
such as hot drinks, and acrid or caustic preparations, into the mouth ; 
difficult dentition ; and probably sympathy with disordered states of the 
stomach. It occurs not unfrequently as a secondary affection, particu- 
lar!}' in the course of measles, scarlet fever, and small-pox. 

The symptoms of eiythematous stomatitis are more or less vivid redness 
of the mucous membrane, sometimes diffused, and at others punctuated or 
disposed in patches; slight swelling of the same tissue; heat; and tender- 
ness to the touch, and also in the act of sucking or eating. The child is 
generally fretful and restless, and either loses its appetite, or refuses to 
nurse or take food freely, on account of the tenderness of the mouth. 
There are seldom any general symptoms except in secondary cases, in 
which they are those of the primary affection. 

The treatment is very simple. It consists in the use of some demulcent 
wash, as gum-water, sassafras-pith mucilage, a little honey put on the 
tongue occasionally, and if the inflammation be at all considerable, in the 
application of some astringent preparation. This may consist of honey 
and borax, two or three parts of the former to one of the latter, or of the 
following wash, recommended by M. Bouchut : 

R.— Mel. KosaB, . . . . . . fgj. 

Aluminis, ...... gss. 

Aquse distillat., f^ss. — M. 

The application of any of the washes recommended is best made by 
means of a thick and soft camel's-hair pencil ; or it may be done with a 
soft rag, which should be dipped in the wash, and then conveyed into the 
mouth on the point of the finger. The remedy ought to be used several 
times a day. 

If signs of gastric or intestinal disorder are present, they should be at- 
tended to. 



AETICLE II. 

APHTHAE. 

Definition; Synonymes; Frequency; Forms. — The term aphthae 
ought to be restricted to the vesicular and ulcerous form of disease of the 
buccal mucous membrane, in which that tissue is covered with an erup- 
tion of vesicles which break, and are followed by small rounded ulcera- 
tions. Under this title writers formerly confounded the affection we are 
now considering with ulcerative stomatitis and thrush. It is called by 
Billard follicular stomatitis, and by several other writers vesicular sto- 
matitis. 



270 APHTHA. 

The frequency of the disease is very considerable. \Te shall describe 
two/brwis, the discrete and con fluent. 

Causes. — The only causes which seem to have been ascertained with 
any degree of certainty are earl}- age and the process of dentition ; the 
contact of irritating substances, particularly stimulating and acrid articles 
of food, with the mucous membrane of the month; and the existence of 
some morbid irritation of the digestive tube, especially of the stomach. 
The confluent form is often connected with severe general disease of the 
constitution. 

Symptoms; Duration. — Aphthae begin in the form of small red eleva- 
tions, having little white points upon their centres, which consist of the 
epithelium of the mucous membrane raised into vesicles. The vesicles 
are small in size, oval or roundish in shape, and of a white or pearl color. 
They soon break and allow the fluid which they contained to escape, after 
which there remains a little rounded ulcer, with excavated and more or 
less thickened edges, and surrounded almost always by a red circle of in- 
flammation. The bottom of the ulcers is usually of a grayish color. 1 
There is seldom any diffuse inflammation of the mucous membrane in 
this disease. The number of aphthae varies in the two forms. In the 
discrete variety there are but few, whilst in the confluent form the}' are 
of course much more numerous. They generally appear first on the in- 
ternal surfaces of the lips and gums, and then on the inside of the cheeks, 
edges of the tongue, and soft palate. 

The discrete form is generally accompanied by symptoms of slight dis- 
order of the digestive organs, consisting of thirst, acid eructations or 
vomiting, imperfect digestion, and a little constipation or diarrhoea. The 
confluent form, which is much more rare, especially in very young in- 
fants, usually coincides, as has already been stated, with severe general 
or local disease. 

The duration of aphthae is different in the two varieties of the affection. 
The discrete form generally pursues a rapid progress, lasting, usually, 
from the beginning to the time of cicatrization, between four and seven 
days. Sometimes, however, when the vesicles are formed successively, 
one after the other, the disease lasts much longer. The confluent variety 
pursues a much slower progress, and is much more difficult of cure. 

Diagnosis and Prognosis. — The diagnosis of discrete aphthae is not at 
all difficult, in consequence of their being isolated and succeeded by small 
and limited ulcerations. The confluent form, on the contrary, may be 
confounded with ulcerative or ulcero-membranous stomatitis, and with 
thrush. From the first-mentioned disease it may be distinguished, how- 
ever, by attention to the circumstances that that affection begins by small 
white patches, and not by pustules, as do aphthae; that the ulcerations 

1 The grayish or yellowish-gray secretion, on the base of the aphthous ulcers, has 
lately been closely studied by Dr. J. "Worms (Glasgow Med. Jour., July, 1864), who 
states that both microscopical examination and chemical tests invariably show its 
sebaceous nature. It is his opinion, therefore, that aphtha? are the acne of the mu- 
cous membranes; in support of which, it will be remembered, that they are found 
most frequently where the muciparous glands are most abundant. 



TREATMENT. 271 

which follow the patches are covered with true pseudo membrane ; and 
that the white patches just spoken of appear first upon the gums, whilst 
aphtha? generally begin upon the posterior surface of the inferior lip, and 
upon the tongue. From thrush it is to be distinguished by the facts that 
that disease commences by white points, which are not pustular, and 
which, running together, form a creamy exudation ; by the absence or 
very small number of ulcerations ; and by the presence of the peculiar 
fungus of thrush. 

Discrete aphtha? constitutes a very mild disorder. The} T always recover 
without much difficult}'. The confluent disease is more serious, because 
its progress is much slower, its cure more difficult, and because it is 
often connected, as has been stated, with some other severe disease. 

Treatment. — Aphtha?, particularly the discrete variety, require in 
general, very simple treatment. The means to be employed are general 
and topical. 

The discrete variety usually requires only topical remedies, regulation 
of the diet, and when there are marked symptoms of gastric derangement, 
the exhibition of some mild emetic, or of a laxative dose. The local treat- 
ment should consist of applications of demulcent preparations, as the 
mucilages of slippery elm, sassafras pith, flaxseed, marsh-mallow root, 
quince seed, &c, which are to be used pure when there is no pain, or with 
the addition of a few drops of laudanum or wine of opium, when the 
mouth is sore and tender ; the aphthae ought to be touched occasionally 
with the mixture of borax and honey, or the aluminous preparation rec- 
ommended for simple stomatitis. The applications must be made seve- 
ral times a day with a camel's-hair pencil, a pencil made of charpie or 
cotton, or with a soft rag covering the finger. When the ulcers which 
follow the vesicles fail to cicatrize rapidly under the above applications, 
or when the} r are numerous and painful, their cure may be very much 
hastened and the pain quickly relieved, by touching them lightly with a 
stick of nitrate of silver, or a piece of alum, sharpened to a point; or we 
may employ a pencil dipped into a strong solution of nitrate of silver, or 
into a mixture of one part of muriatic acid to two of honey. Ether has 
been highly recommended as a local application by Dr. J. Worms who, 
as already stated, has observed the fatty nature of the deposit in aph- 
thous ulcers. 

The general treatment of discrete aphtha?, need consist of nothing more 
than the prescription of a simple, unirritating diet in most of the cases. 
If, however, the digestive apparatus is deranged, the case must be treated 
according to the symptoms ; by antacids or a gentle emetic, when the 
tongue is foul and the secretions acid, and by the use of a mild laxative, 
as castor oil, magnesia, or rhubarb, when there is constipation. When 
diarrhoea is present, we should resort first to a small dose of castor oil 
or sj^rup of rhubarb, with the addition of half a drop to two drops of 
laudanum, according to the age of the child, and afterwards to astrin- 
gents and opiates, as will be recommended in the article on simple diar- 
rhoea. 

The treatment of confluent aphthae must depend on their cause. The 



272 ULCERATIVE STOMATITIS. 

local treatment is the same as that for the discrete variety, except that 
cauterization should be resorted to at an earlier period. When they seem 
to depend upon a general morbid condition of the constitution, as con- 
genital debility, a scorbutic diathesis, or upon chronic affections of the 
digestive organs, the}^ must be treated in the first place by properly regu- 
lated and nutritious diet, and by the exhibition of tonics and gentle 
stimulants, particularly iron, quinine, and small quantities of very fine 
old brandy ; and in the second case, in the manner which will be recom- 
mended for chronic derangements of the stomach and bowels, when we 
come to treat of the diseases of those organs. 



ARTICLE III. 

ULCERATIVE OR ULCERO-MEMBRANOUS STOMATITIS. 

Definition ; Synonymes ; Frequency. — This form of sore mouth is 
characterized by a secretion upon the mucous membrane of a plastic ex- 
udation in thick, yellowish, adherent patches, and by inflammation, ero- 
sion, or ulceration of the subjacent tissues. It is the same disease as the 
aphtha gangrenosa, and, we believe, the cancrum oris also of Underwood ; 
the ulceration of the mouth of Dewees and Eberle ; the stomatite couen- 
neuse, and the ulcerative and pseudo-membranous forms of the stomatite 
gangreneuse of M. Yalleix ; the stomatite pseudo-membraneuse or diph- 
theritique of some writers ; and the stomatite ulcero-membraneuse of MM. 
Rilliet and Barthez. It is the disease described under the title of gan- 
grenous sore mouth by Dr. B. H. Coates {North American Surgical and 
Medical Journal, vol. ii, 1826), with the exception of a few cases which 
were what we shall treat of as gangrene of the mouth. 

Of the different titles given above, we prefer that of ulcero-membra- 
nous stomatitis, as most expressive of the distinctive features of the dis- 
ease. This form of stomatitis is not very frequent in private practice, 
but sometimes prevails extensively in hospitals, and other public institu- 
tions for children, where it often assumes an epidemic character. 

Causes. — The predisposing causes are epidemic influence, of , the ex- 
istence of which Ave believe there is no doubt ; according to some observers, 
contagion, which, however, has not as yet been positively shown ; and 
bad hygienic conditions as to cleanliness, ventilation, food, clothing, and 
habitation. That it is epidemic, we have no doubt from our own experience, 
since we are rarely called to a case without soon meeting with others, 
while we sometimes pass several months without seeing a single example 
of the disease. We have also known it to be endemic in a household, 
having on one occasion met with seven cases in two families of children 
residing under one roof, on two other occasions with three cases, and on 
several others with two. It is most frequent between the ages of five and 



SYMPTOMS. 273 

ten years, though it may attack all ages, and is more common in boys 
than girls. It occurs during the convalescence from severe diseases, as 
pneumonia, the eruptive fevers, typhoid fever, entero-colitis, and other 
affections of children. 

The exciting causes of sporadic cases are unknown, with the exception, 
perhaps, of the presence of a carious tooth in the mouth, and fracture or 
necrosis of the maxillary bones. 

Symptoms ; Course ; Duration. — The disease begins with slight pain 
and uneasy sensations in the gums, which then become swelled, red, bleed- 
ing when touched, and are soon after covered with a grayish, pultaceous 
exudation of varying thickness. The exudation extends from the gums 
to the internal surface of the lips and cheeks, and sometimes, but more 
rarely, to the soft palate, and even to the pharynx and nasal passages. 
The plastic deposit occurs in the form of small, and slightly projecting, 
j-ellowish patches, which approach each other, unite, and form bands of 
pseudo-membrane, somewhat uneven upon the surface, and adhering with 
considerable force to the tissue beneath. When the exudation is detached, 
the mucous membrane is found to be of a red or purple color, bleeding, 
and excoriated or ulcerated. The ulcerations which exist under the false 
membrane are of various depths, of a grayish, livid, or blackish color, 
with swelled, softened, and livid red, or bleeding edges. Those which 
are formed upon the inside of the lips are rounded in shape, whilst those 
seated in the angle between the lips and gums, are usually elongated. In 
mild cases of this affection, the local symptoms, though perfectly char- 
acteristic, are less severe than those just now described. The ulcerations 
are often few in number, amounting to four, five, or six upon the tongue, 
to a few scattered over the inner surfaces of the lips, and to some upon 
the gums, and especially about the necks of the teeth. The other symp- 
toms are the same as those above mentioned, with the exception that 
they are milder in degree. 

When the disease is mild, and when it is properly treated, the false 
membranes become detached, leaving the mucous tissue merely excori- 
ated, in which case it soon regains its natural condition ; or else the ulcers 
which exist beneath rapidly become healthy and cicatrize. In violent 
cases and in those badly treated, the inflammation, on the contrar}^ per- 
sists ; the pseudo-membranes increase in thickness, or if detached, are 
formed anew ; the ulcerations become deeper ; the disease extends ; and 
the case lasts an indefinite period of time. 

Other symptoms, besides those we have mentioned, characterize the 
disease. 

The breath is always more or less fetid, and in bad cases, almost gan- 
grenous. The salivary and submaxillary glands are generally more or 
less swelled, hard, and painful, and according to some authors, the sur- 
rounding cellular tissue is in the same condition, though this is denied 
by others. The movements of the lower jaw are stiff and painful in severe 
cases. Deglutition is not affected unless the disease extends to the phar- 
ynx. In violent cases there is usually a copious discharge of fetid, 
watery saliva, or of bloody serum, which flows from the mouth during 

18 



274 ULCERATIVE STOMATITIS. 

sleep. When the ulcerations are deep and large, the tissues beneath are 
more or less swelled ; the swelling, however, rarely assumes the hard, 
resisting, circumscribed characters, with the tense, smooth, hot, and shin- 
ing appearance of the skin, which exists in true gangrene of the mouth. 
In most of the cases there is a moderate, but decided febrile reaction, 
especially at the invasion. This usually subsides or disappears after two 
or three days, though it sometimes increases if the disease becomes ex- 
tensive. 

The disease begins, as already stated, on the gums, and unless limited 
to these parts, as sometimes happens, extends to the lips and cheeks. In 
many of the cases it attacks only one side of the mouth, and this is more 
frequently the left than the right. 

The course of the disease is usually rapid in epidemic cases, and in 
those which are properly treated. Where badly treated, on the contrary, 
it may last from one to several months, or terminate in gangrene of the 
mouth. 

Diagnosis ; Prognosis. — The diagnosis is, as a general rule, very easj T , 
if proper attention be paid to the characteristic features of the disease. 
It has, as already stated, been very often confounded with gangrene of 
the mouth. The method of distinguishing between the two will be given 
in full in the article on that disease. From thrush it is to be distinguished 
in the manner which will be pointed out when that disease comes under 
consideration. 

The prognosis is favorable in the great majorny of the cases. Sporadic 
cases probably always terminate favorably. The epidemic disease, though 
rarely fatal, sometimes proves so from its extension to the phar3 T nx and 
larynx, or from its termination in gangrene of the mouth. We have seen 
a large number of cases in private practice, and have never as jet known 
one to become gangrenous or to prove fatal. Of upwards of 120 cases 
of this kind, observed by Dr. Coates at the Philadelphia Children's Asy- 
lum, in a period of three months, all but one recovered (Joe. cit., p. 21). 
The cases which occur in the course of other diseases are not dangerous 
in themselves, but are so as being the sign of a great severity of the pri- 
mary affection. 

Treatment. — The treatment may be divided into general, and local or 
topical. The general treatment should consist in most of the cases in 
attention to the diet, which ought, in healtlry and vigorous children, to 
be simple and unirritating, and in those who are weak and debilitated, 
nutritious and digestible. If the bowels are costive, or the child feverish 
and uncomfortable, a laxative dose may be given with advantage; or 
some simple diaphoretic, as nitre and water, or the neutral mixture, may 
be used through the day, and a warm foot-bath or an immersion bath 
given in the evening. When the constitution is feeble, and the child 
weak or ansemic, tonic remedies are indicated. The best is probably 
quinine, or one of the ferruginous preparations ; or the compound infu- 
sion of gentian, with addition of Huxham's tincture of bark, may be 
resorted to. If the inflammation be severe, and accompanied with tume- 
faction and tenderness of the glands and some febrile reaction, it might 



TREATMENT. 275 

be proper to apply a few leeches to the neck, though we have never found 
this to be necessary. The best internal remedy, however, and indeed the 
only one of any kind that is necessary in most cases, is the chlorate of 
potash, which possesses a stimulant and alterative action upon the mu- 
cous membranes. This is spoken of in the highest terms by Dr. West, of 
London, who regards it almost as a specific. We have used it now for 
many years past in a very large number of cases, and have seldom found 
it necessary to employ any other means, excepting some mild cathartic 
dose where the bowels have been constipated, and a wash of borax or alum 
in hone}' of roses, or borax in simple honey. The symptoms have begun 
to amend in every case in from three to four or five days, and recovery 
has taken place in about a week or a little more. The dose is from two 
to three grains every four hours for a child three 3 T ears of age, and four 
and five grains for one of nine or ten years. Mr. Hutchinson (Med.. 
Times and Gaz., 1856) who believes also that this salt is almost a spe- 
cific in this affection, recommends it in larger doses than the above, giv- 
ing as much as five grains, thrice daily, to an infant of one year old. We 
have usually prescribed it in the dose of two grains four times a day, in 
a mixture of syrup of ginger and water, for children three or four years 
old. 

Prior to the discovery of the efficacy of the chlorate of potash in this 
affection, the local treatment constituted the only effectual and reliable 
means of removing it, and the most violent and painful applications were 
thought necessary and were made use of. Strong solutions of nitrate of 
silver, and pure or diluted muriatic acid, were frequently employed in 
severe cases. Xow, however, these caustic substances may probably be 
entirely dispensed with, except in cases that show a tendency to assume 
the form of gangrene of the mouth. In ordinary cases the only local ap- 
plications that need be used, and these are not essential when the child 
resists very much, are demulcent washes to keep the mouth clean — to be 
empkyed in the manner recommended in the article on aphthae, and some 
mild astringent wash. This may consist of borax and honey, or borax 
and sugar, in the proportion of two or three parts of the former to one 
of the latter, or, what is in my opinion preferable to either of these, of a 
drachm of borax rubbed up with an ounce of honey of roses. 

Should the disease resist the treatment by the chlorate of potash and 
the simple washes just now recommended, we may employ the following 
combination, proposed by Dr. Dewees, and of which he says that it " has 
so far never failed us : " 



. — S ul ph. Cupri, . 


. g X. 




Pulv. Cinch. Opt, 


• • • • #j. 




Pulv. G. Arab., 


. gi. 




Mel. Com num., . 


f#j. 




Aquse Font., . 


igiij. 


— M. et ft. sol 



The ulcerations to be touched with the mixture twice a da}', with the 
point of a camel's-hair pencil. Or, we may resort to the following one, 



276 GANGRENE OF THE MOUTH. 

recommended by Dr. Coates (loc. cit.). and of which he sa3 r s, that he "set- 
tled down, after various trials, in the employment of the following : 

R.— Sulph. Cupri, gij. 

Pulv. Cinchona?, ...... i|ss. 

Aquas, f^iv- — ^« 

To be applied twice a day, very carefully, to the full extent of the 
ulcerations and excoriations." 

MM. Rilliet and Barthez recommend very highly the plan pursued by 
M. Bouneau at the Children's Hospital. This is to cleanse the mouth 
first, and then to apply dry chloride of lime (calx chlorinata of the Phar- 
macopoeia) to the diseased surfaces. The application is made by means 
of a piece of rolled paper, or a stiff pencil, which is to be moistened and 
then dipped into the powder so that some may adhere, or with the finger. 
The surfaces are to be gently rubbed with the powder, and after a few 
moments' contact, washed clean with pure water. This is to be done 
twice a day, until the ulcerations assume a clean, healthy appearance, 
after which the following mouth-wash is to be employed : 

R.— Mucil. G. Acac, f^i. 

Syrup Cort. Aurant., ..... fjfss. 
Calc. chlorinat., £)i. — M. 

The chief danger from the disease depends on the circumstance that it 
sometimes terminates in gangrene of the mouth, to be presently described. 
Any disposition to such a termination should be carefully watched, and 
the proper preventive means, consisting of local stimulating or caustic 
applications, with the internal use of stimulants and tonics, be at once 
resorted to. 



AETICLE IV. 

GANGRENE OF THE MOUTH. 

Definition ; Synonymes ; Frequency. — Gangrene of the mouth is an 
affection which occurs chiefly in children of debilitated constitution, and 
especially as a sequel of some of the eruptive fevers. It begins generally 
by ulceration of the mucous membrane of the cheek, which, after a longer 
or shorter time, runs into gangrene, and extends rapidly to the gums ; 
after a few days, if the disease be not arrested, the central tissues of the 
cheek become thickened and indurated, an eschar forms upon the integu- 
ment, and spreads in depth and width, until at last the cheek may be 
perforated, the whole side of the face and jaws destroyed, the teeth loos- 
ened, and the maxillary bones exposed and necrosed. It is known by a 
great variety of names ; grangraenopsis, cancrum oris, gangrama oris, 
canker of the mouth, gangrenous erosion of the cheeks of Underwood ; 



ANATOMICAL LESIONS. 277 

necrosis infantilis, gangrenous stomatitis, &c. It is a frequent disease 
in the hospitals for children in Europe, and a not uncommon one in in- 
stitutions of the same kind in this country. It sometimes prevails en- 
demically in hospitals. It is a rare disease in private practice, and we 
have as yet met with but few cases, excepting in public institutions. 

Predisposing Causes. — The disease is nearly, but not exclusively con- 
fined to the period of childhood. It is most common between the ages of 
three and six years; is very rare, but does sometimes occur in infants; 
and is of nearly equal frequency' probably in the two sexes. Unfavorable 
hygienic conditions constitute a strong predisposing cause. Children 
living in hospitals or airy crowded institution ; those whose parents are 
poor or in want, and whose constitutions have been greatly deteriorated 
by long illness, by the tubercular diathesis, or by acute diseases, are 
particularly apt to be attacked. It almost always follows upon some 
previous acute or chronic disease, particularly measles, or some other 
acute exantheme; pneumonia; enterocolitis; hooping-cough; long-con- 
tinued malarious fevers, &c. MM. Guersant and Blache say (Diet, de 
Med., t. 28, p. 601), " The existence of some anterior disease is a neces- 
sary condition of gangrene of the mouth ; we have never known it, nor 
has M. Baron, to occur as an idiopathic affection." It has been affirmed 
by some persons to be contagious, but this is exceedingly doubtful. The 
fact of its occurring sometimes in an endemic form has already been 
referred to. It has been known also to prevail as an epidemic. 

The exciting causes can rarely be ascertained with any certainty. The 
only one which seems to have been proved to exist in some instances, is 
the exhibition of large doses of the mercurial preparations, and even this 
is questioned by some very good authorities. 

Anatomical Lesions. — Upon examination after death, it is found that 
the integument surrounding the mortified spot soon runs into putrefaction. 
The lip or cheek in which the disease is seated is swelled, hardened, 
tense, and shining, of a purple or greenish color, and presents a deep, 
circumscribed engorgement. On the most prominent part of the swell- 
ing there often exists a rounded or oval, and distinctly limited eschar, of 
variable size, from a third of an inch to an inch or even more in diameter. 
In some instances the cutaneous slough is much larger, and extends ir- 
regularly to different parts of the face, to the chin, neck, eyelids, and 
even to the neighborhood of the ear, so as to occupy the whole of one 
side. Under these circumstances, the tumefaction is neither so consider- 
able, nor so regular, as when the slough is smaller. The eschar is always 
black, and generally dry and parchment-like, and extends a third or two- 
thirds of a line in depth, or quite through the integument. The tissues 
beneath the skin are not generally implicated, though in some cases the 
eschar is detached, and there is a perforation of the cheek through which 
may be seen the alveolar processes. 

The mucous membrane of the mouth is alwa} T s affected with mortifica- 
tion. The disease may be limited, so as to exist in the form of an elon- 
gated ulceration, of a dark grayish color, situated in the fold where the 
mucous membrane is reflected from the cheek to the lower jaw; or, in a 



278 GANGRENE OF THE MOUTH. 

larger proportion of cases, it is seated on the internal surface of the cheek, 
opposite the interval between the alveolar processes. Sometimes the 
disease is much more extensive, and occupies all or a part of the internal 
surface of the cheek. In such instances the whole thickness of the mu- 
cous tissue is destroyed, and it presents upon its surface a blackish or 
brownish pultaceous slough, almost liquid in consistence, which may be 
scraped off with a scalpel, leaving beneath loose shreds of mucous mem- 
brane, without any trace of organization. The gums frequently par- 
ticipate in the disease, and are converted into shreds, or completely 
destroyed. 

The maxillary bones are sometimes, in severe cases, when the disease 
has extended to the gums, exposed, blackened, and even necrosed. The 
teeth are very often uncovered and loosened, and not unfrequently some 
are lost. The tissues between the skin and mucous membrane are found 
either hardened and infiltrated, or sphacelated to a greater or less extent. 
In the least severe cases, the fatty cellular tissue and the muscular struc- 
ture of the cheek are infiltrated with serum, but preserve their organiza- 
tion. When the disease is more aggravated, the gangrene extends to 
these tissues also, and always to those adjoining the mucous membrane 
first ; so that the cellular structure beneath that membrane, and then the 
muscles, are infiltrated with a sanious fluid, and either in a state of spha- 
celus or tending thereto, whilst some of the adipose tissue beneath the 
skin is still merely infiltrated. In yet worse cases, the sloughs formed 
on the two surfaces of the cheek come into contact, and if their separa- 
tion from the sound parts has taken place, a perforation is the conse- 
quence. 

The condition of the bloodvessels in the midst of the diseased parts has 
been carefully examined by MM. Killiet and Barthez. These authors state 
that when the tissues of the cheek are merely infiltrated, the vessels re- 
main healthy, permeable, and their parietes are scarcely or very slightly 
thickened. When the vessels run along the edge of the slough, they are 
still permeable, but their walls are thickened, and begin to assume the 
appearances of the mortified tissues. Lastly, when the}' traverse the 
centre of the eschar, they can still be traced out, but their canals are 
found obliterated by coagula, in the whole extent of the mortified parts ; 
or else the coagula occupy the vessels at their points of entrance into 
and exit from the slough, while between these points their walls are 
thickened, tend to assume the color and softness of the putrefied tis- 
sues, and their canals are filled with pultaceous gangrenous matter. The 
writers quoted do not suppose that the obliteration of the vessels is the 
cause of the sphacelus, since that change occurs only after the death of 
the surrounding tissues has already taken place. 

The disease very rarely occurs on both sides of the mouth at once, 
though this does occasionally happen. 

The submaxillary glands are nearly always in their natural condition, 
but in rare instances are softened and engorged. 

Gangrene of the mouth never, or very rarely, indeed, exists without 
lesions of other organs. Of these the most frequent are acute pulmonary 



SYMPTOMS. 279 

affections, and after them, acute or chronic diseases of the gastrointes- 
tinal tube, and then malarious fevers, pleurisy, pneumothorax, perito- 
nitis, and nephritis. 

Symptoms ; Course ; Duration. — The following account of the symp- 
toms of the disease is taken chiefly from the work of MM. Rilliet and 
Barthez. Gangrene of the mouth generally begins during the course or 
convalescence of some acute or chronic disease, by ulceration, aphthae, 
or phlyctense of the mucous membrane, and, in rare instances, by oedema 
of the substance of the cheek. At the same time the face is pale, and 
usually continues so throughout the disease ; the nostrils and eyelids are 
often incrusted, and the latter infiltrated or sunken, and surrounded by 
bluish circles ; the lips are swelled and covered with scabs, or dry. The 
breath of the child is fetid from the beginning, and, as the disease pro- 
gresses, becomes gangrenous. There is but little fever at first, unless the 
case be accompanied by some acute disease ; the pulse is commonly fre- 
quent and small in the beginning, rising gradually from 80 or 90 to 100 
or 120, and becoming insensible towards the end. In cases occurring in 
the course of other diseases, the pulse rises sometimes to 120 or 140, and 
is larger and fuller. The child is generally languid and quiet at first, or 
more rarely cross and peevish. The strength may be either lost entirely, 
merely diminished, or the patient may retain a sufficient amount of force 
to sit up and observe what is going on around, and even to leave the bed 
the day before death. Half the children observed by MM. Killiet and 
Barthez, in whom this symptom was noted, sat up in bed until within a 
few clays of the fatal termination. In most cases but little complaint is 
made of pain in the mouth, though in some it is said to be severe. 

The ulceration already spoken of as forming the first symptom of the 
disease is generally of a grayish color, and resembles very closely that 
which exists in the ulcero-membranous form of stomatitis. It may be 
seated either on the gums, in the fold formed by the junction of the cheek 
or lip with the gum, or on the inside of the cheek, opposite the space be- 
tween the alveolar processes. It may present a gangrenous appearance 
from the first day, or not until after two or three clays ; or lastly, it may 
pass through the stages characteristic of ulcerative stomatitis, and ter- 
minate in the affection under consideration. Dr. B. H. Coates (loc. cit.) 
describes, under the title of gangrenous sore mouth of children, the 
ulcero-membranous form of stomatitis, and a few cases of gangrene, and 
states that three or four children out of 120 affected with ulcerated gums 
" suffered small spots of mortification, and one, by the delay arising from 
the tardy report of a nurse, suffered necrosis in a portion of an alve- 
olus." 

The ulcerations just described assume the following appearances as the 
gangrenous nature of the malady develops itself. They become grayish, 
and then dark in color, bleed easily when touched, and are covered with 
pultaceous sloughs, exhaling a characteristic fetid odor. The gangrene 
extends to the neighboring parts, from the gum to the cheek, or from the 
cheek to the gum, and implicates at last the whole side of the mouth, or 
of the lower lip. At the same time the affected cheek or lip undergoes a 



280 GANGRENE OP THE MOUTH. 

circumscribed infiltration, which is at first rather soft, but becomes after- 
wards firmer, and forms at last a hard and rounded knot or tumor in the 
centre of the cheek, which is now tense, shining as though smeared with 
oil, and pale, or marbled with purple spots, while the slough on the inside 
is of a brownish color, more extended in size, and sometimes surrounded 
by a dark ring. The hard tumor of the cheek jnst described usually ap- 
pears between the first and third daj 7 s after the sphacelation of the mucous 
membrane, though in some instances not until a later period. It is formed, 
as stated in the account of the anatomical lesions, by engorgement of the 
cellular and adipose tissues. The child, at this stage, is still able to sit 
up in bed and take notice, or shows evident signs of weakness and de- 
pression ; the face is swelled and destitute of expression on the affected 
side ; a bloody or dark-colored saliva runs from the mouth, which is par- 
tially open ; the appetite is not entirely lost in all cases, the patient still 
demanding and taking food ; vomiting is rare, but diarrhoea is almost 
alwaj 7 s present ; the thirst is generally intense ; the skin is warm and 
feverish, natural, or too cool, and almost alwa}~s dry, the differences de- 
pending probably more upon the concomitant disease than upon the 
mouth-affection. The respiration is natural or altered according to the 
nature of the primary disease, which is, as already stated, in a large pro- 
portion of the cases, a pulmonary affection. The intelligence is generally 
undisturbed, though in some rare cases there is insomnia, delirium, or 
piercing cries. 

If the disease continues to progress, as it almost always does when it 
has reached the stage we are describing, there appears in man} 7 , but not 
all the cases (8 of the 21 observed by MM. Rilliet and Barthez), a slough 
or eschar upon the most prominent and discolored part of the swelling of 
the integument of the cheek or lower lip. This generally makes its ap- 
pearance between the third and sixth clays of the disease, but in other 
cases, as early as the second, or not before the twelfth, or even later. The 
skin, at the point where the eschar is about to form, becomes purple, and 
then black ; sometimes a phlyctsena makes its appearance, which is very 
soon converted into a small, dry, black slough. This, if not limited by a 
j)rocess of separation from the living tissues, becomes larger and larger 
by the extension of the sphacelation, until it may, as already stated, em- 
brace the whole side of the face. In grave and fatal cases, the gangrene 
sometimes extends to all the tissues of the cheek, and meeting, at last, 
the disease which had commenced on the inside of the mouth, occasions 
a perforation, through which may^be seen the teeth, alveolar processes, 
and the whole interior of the buccal cavit} 7 . In such instances as these, 
several of which we have seen in the Penns3 T lvania and Philadelphia Hos- 
pitals, the appearance presented by the child is, as may well be imagined, 
of the most pitiable kind. Even under these circumstances, however, 
with the cheek perforated, the edges of the opening irregular and cov- 
ered with shreds of dead tissue, the gums destro} 7 ed, the teeth loosened, 
and the maxillary bones exposed, blackened, and perhaps necrosed, with 
a dark and fetid sanies flowing from the mouth or perforation, and a putre- 
factive smell infecting the air around, the child may retain, in some in- 



DIAGNOSIS. 281 

stances, its strength, so as to sit up in bed, ask for food, and drink with 
avidity. In other eases, on the contrary, the patient, at this stage, is ex- 
hausted to the last degree, and refuses both food and drink. During the 
closing stage of the disease there is generally profuse diarrhoea, rapid 
emaciation, dry skin, small, rapid pulse, and at last death in a state of 
utter prostration. 

In favorable cases the recovery may take place in the early stage, be- 
fore the integument becomes involved, and while the gangrene is limited 
to the mucous membrane, or at a later period, after the slough has sepa- 
rated. In the first instance the child generally recovers without deform- 
ity, though we saw one case in which necrosis of about an inch of the 
front of the inferior maxilla took place, without any loss of the soft parts. 
When the child recovers after the formation of the cutaneous slough, a 
very rare event, the gangrene ceases to extend, the eschar separates and 
is cast off, the edges of the opening assume the appearances of a healthy 
ulcer, and after a length of time, approach each other and cicatrize, leav- 
ing generally a large, uneven, discolored scar, like that of a burn, which 
remains through life a horrid deformity. 

The duration of the disease varies according to its termination. When 
this is unfavorable, which happens in much the larger proportion of cases, 
death usually occurs about the end of the first, or in the course of the 
second week, though it has been known to occur at a later period. In 
favorable cases the duration is commonly longer, particularly if a cutane- 
ous eschar has been produced, as the separation of the slough and cica- 
trization of the ulcer which remains, require a tedious and slow process 
on the part of nature. 

Complications are very apt to arise in the course of the disease. The 
most frequent is pneumonia. MM. Guersant and Blache state that it 
exists in nine-tenths of the cases ; MM. Killiet and Barthez found it in 19 
out of 21 ; of the 19, it began in 8 during the progress of the gangrene, 
and apparently under the influence of the latter, whilst in the remaining 
cases it existed before, and acted perhaps as a predisposing cause to the 
affection of the mouth. Another and more dangerous complication is the 
occurrence of gangrene in other parts of the body, particularly the soft 
palate, phaiynx, oesophagus, anus, and more frequently the vulva and 
lungs. 

Diagnosis. — Some authors have described as identical affections, under 
the title of gangrenous stomatitis, the disease under consideration, and 
the one already treated of as ulcero-membranous stomatitis. This has 
been done particularly by M. Taupin, who is followed in his description 
by M. Yalleix {Guide du Med. Prat., t. iv). It seems clear to us, more- 
over, that Dr. B. H. Coates, in his very valuable paper on the " gangre- 
nous sore mouth of children" (Joe. cit.), mingles in his description the 
two diseases referred to. We cannot but think, however, that the dif- 
ferences between them as to frequenc3 r , sjmiptoms, course, amenability 
to treatment, and termination, which are fully pointed out in the diag- 
nostic table below, and lastly the example of almost all authors upon this 



282 GANGRENE OF THE MOUTH. 

subject, fully warrant us in regarding them as different and distinct 
diseases. 

The diagnosis of gangrene of the mouth is, in most cases, very easy. 
The ulceration of the mucous membrane, followed hy gangrene ; the deep- 
seated induration of the cheek, at first pale on the outside, then dark- 
colored, and terminating after a time in a characteristic slough; the 
course of the malady, and the nature of the general symptoms, will gene- 
rall} T prevent an} 7 difficult} 7 in the recognition of the disease. 

From stomatitis it may be distinguished by attention to the points laid 
down in the following table, taken from MM. Rilliet and Barthez : 

STOMATITIS. GANGEENE. 

Beginsby ulceration or by pseudo-inein- Begins by ulceration, which is some- 

branous plastic deposit. times gangrenous from the first, or by 

oedema of the cheek. 

Odor very fetid and sometimes gangre- Odor always gangrenous, 
nous. 

But little extension of the local lesion, Considerable and rapid extension ; the 

which always retains the same appear- tissues assume a peculiar dark grayish 

ances. tint. 

But little swelling of the cheek or lips, Extensive swelling and oedema of the 
or simply oedema of those parts, without cheek, with deep-seated induration, ten- 
deep-seated- induration, tension, or unc- sion, unctuous appearance, purple spots, 
tuous appearance. 

Salivation rarely so considerable as to Salivation abundant ; constant escape 

flow from the mouth ; when present some- of fluid, at first sanguinolent, afterwards 

times sanguinolent; never mixed with putrefactive, 
shreds of gangrenous tissue. 

Never an eschar on the exterior. Often an eschar upon the cheek or lips. 

Never complete perforation of the soft Perforation of the soft parts frequent; 

parts; denudation of the bones never oc- denudation of the bones constant ; loosen- 

curs ; loss of the teeth very rare. ing of the teeth constant, and their loss 

frequent. 

Course of the disease slow when left to Course rapid, and termination fatal, as 

itself; recovery rapid under the influence a rule, when the disease is left to itself, 

of treatment. and in spite of all treatment. 

Gangrene of the mouth may be confounded with malignant pustule. 
The method of diagnosis has been drawn by M. Baron in the following 
words : " Malignant pustule always begins on the exterior ; affects the epi- 
. dermis first, and extends successively to the corpus mucosum, chorion, 
and subjacent parts ; whilst, on the contrary, the gangrene under consid- 
eration attacks the mucous membrane first, then the muscles, and lastly 
the skin." 

Prognosis. — The prognosis of true gangrene of the mouth is exceed- 
ingly unfavorable. The great majority of the subjects die in spite of all 
that can be done. Dr. Coates (Joe. cit., p. 14) says that a black spot on 
the outer surface of the swelling "has always been in my own experience, 
the immediate harbinger of death. It is proper to state, however, that I 
have heard it said that cases had recovered in this city, in which the gan- 
grene had produced a hole through the cheek." MM. Rilliet and Barthez 



PROGNOSIS — TREATMENT. 283 

state that "death is the ordinary termination of gangrene of the month; 
though there are instances of recovery on record." Of 29 cases analyzed 
by them, only 3 recovered. MM. Gnersant and Blache (loc. cit., p. 596) 
state that unless arrested in the formative stage, it ends fatally almost 
constantly in from five to ten days, and frequently before perforation has 
taken place. Of 36 cases observed by M. Tanpin in the Children's Hos- 
pital, at Paris, not one escaped (Gnersant and Blache, loc. cit., p. 597). 
The authors of the Compendium de Medecine Pratique, say of this disease 
(t. i, p. 632), " Death is the almost inevitable termination." Dr. Marshall 
Hall (Edin. Med. and Surg. Journ., xiv, p. 547), reports six cases of the 
disease, two of which followed measles, one repeated attacks of pneumonia, 
one fever (type not mentioned), one worm fever, and one typhus fever. 
All but one, the case occurring in the course of typhus fever, in a girl 
twelve years old, died. This girl recovered, with, however, falling-in of 
the right cheek, " a frightful chasm " on the left side of the mouth, and 
caries of a portion of the alveolar process, palate bone, and second molar 
tooth. Recoveries sometimes occur, however, as in the case mentioned 
by Dr. Hall, after perforation, but nearly always with terrible deformities, 
with adhesions of the walls of the mouth to the jaws, with incurable fis- 
tula?, &c. 

The prognosis is more favorable in private practice than in hospitals. 
The favorable circumstances in any case are : good hygienic conditions ; 
vigorous constitution of the child; the absence of dangerous concomitant 
disease ; the continuance of appetite and strength ; and a disposition to 
limitation and separation of the slough. Unfavorable symptoms are : 
weak and debilitated constitution of the patient ; severe coexistent dis- 
ease ; prostration of the strength ; and extension of the sloughing process. 
Death may also occur from hemorrhage in consequence of the separation 
of the slough, as in a case quoted from Hueter by Bouchut. 

Treatment. — The reader need but refer to the remarks on prognosis 
to be assured that no treatment as yet discovered promises much success. 
We would call attention also to the following statement, — that the remarks 
about to be made apply only to true gangrene of the mouth, and not to 
all the cases described by some writers under the title of gangrenous sore 
mouth or even that of gangrene of the mouth, since, as already stated, 
they confound together true gangrene and ulcero-membranous stomatitis. 

The treatment is divided into local and general. The local treatment 
recommended by the French writers, consists in cauterization of the 
sloughing parts with one of the mineral acids, with nitrate of silver, or 
with the actual cautery. This is the plan proposed by MM. Billard, Baron, 
Guersant and Blache, Barrier, Billiet and Barthez, Bouchut, and Yalleix. 
The authors of the Bibliotheque du Medecin Practicien remark, however, 
that nearly all the patients subjected to cauterization die, and that of the 
small number saved, there are as many who had not been subjected to 
that treatment, as there are of those to whom it had been fully applied. 
They wonder, therefore, that recent authors continue to repose the same 
confidence in it, as did their predecessors. " For us," they say. " we are 
of opinion that cauterization exerts but slight influence, if it have any at 



284 GANGRENE OF THE MOUTH. 

all, and it is greatly to be desired that the zeal of practitioners might dis- 
cover some more efficacious remedy." (Loc. cit., t. y, p. 551.) 

It is very important to make use of the caustic application as early after 
the beginning of the sphacelus as possible, for if it be allowed to spread to 
any considerable depth or extent, there is scarcely a hope of arresting 
it by any means. MM. Guersant and Blache recommend pure nitric, sul- 
phuric, or muriatic acid; MM. Rilliet and Barthez propose the acid nitrate 
of mercury, or muriatic, sulphuric, or acetic acid ; M. Talleix proposes the 
treatment employed by M. Taupin, which is to remove the pseudo-mem- 
brane and a part or the whole of the gangrenous eschar with scissors, to 
make some scarifications upon the healtlrv parts, to apply pure muriatic 
acid, and after the fall of the slough, to make use of dry chloride of lime 
(calx chlorinata). The acid most generally employed is the muriatic. 
The local treatment proposed by MM. Rilliet and Barthez is the follow- 
ing: As soon as the ulcerations assume a gangrenous appearance, to touch 
them with a brush or sponge dipped into acid nitrate of mercury, or pure 
muriatic acid, the brush to remain in contact with the sloughs for a few 
instants, and then to be applied rapidly around and on the parts be}*ond 
them. After this cauterization, an application is to be made of dry chlor- 
ide of lime (in the manner recommended in the article on ulcero-membra- 
nous stomatitis), which is to be left in contact with the sloughs for a few 
minutes, when the mouth must be thoroughly washed with a strong jet of 
water from a syringe. The cauterization and use of the chloride of lime 
are to be resorted to twice a day, and the mouth washed three or four 
times in the interval with large injections of simple water, barlej'-water 
mixed with honey of roses, or better still, with a strong decoction of cin- 
chona. If the case goes on favorably, and the sloughs separate, the cau- 
terizations are to be suspended, and the chloride of lime alone employed. 
If, on the contrary, a slough forms on the outside of the cheek, a crucial 
incision must be made into it, and a brush charged with the same caus- 
tics introduced between the cuts ; powdered cinchona is then placed in 
the openiugs, and retained there by a piece of diachylon plaster, or by 
pledgets of charpie, dipped in a solution of soda. This treatment is to 
be continued until the slough separates, when the edges of the wound, 
and all the diseased parts that can be reached, are to be cauterized. 

In applying escharotics to the mouth, certain general precautions are 
required, of which it is necessaiy to give some account. When the}' are 
used upon the inside of the cheek, a spoon must be introduced into the 
mouth, with the concavity directed towards the alveolar processes, in order 
to preserve the teeth and tongue from being touched. When the appli- 
cation is made upon the gums, the cheek should be drawn to one side by 
an assistant, and the tongue pushed out of the waj T with the finger, or a 
spoon. If the acid happen to touch the teeth or tongue, it must be in- 
stantly washed off. The mouth ought always to be thoroughly cleansed 
with water immediately after the cauterization, to remove any super- 
abundance of acid. 

The kind of brush most suitable for the application of the mineral acids 
is one made of charpie, strongly tied to a solid handle. The sponge-mop, 



TREATMENT — LOCAL APPLICATIONS. 285 

which is sometimes used, is made by fastening a small piece of fine sponge 
to the end of a stick. 

MM. Guersant and Blache recommend that the acid be applied to the 
slough every hour, until the sphacelus ceases to extend. They state that 
this plan is sometimes advantageous when the gangrene is confined to the 
gums only, but that it is generally powerless when the disease has ex- 
tended to the cheek, or has implicated the deep-seated tissues. Under 
the latter circumstances, and when the inefficacy of caustic has been 
shown by trial, they propose the use of the actual cautery, as recom- 
mended by M. Baron, and other distinguished practitioners, and which, 
they add, has afforded them some brilliant results in very bad cases. 

M. Barrier advises that we should accurately expose the diseased parts 
by crucial incisions, and apply the escharotic to all the parts forming the 
limits of the gangrene, in such a way that the tissues already disposed 
to slough shall be thoroughly cauterized, while those a little beyond are 
so in a less degree. 

In applying these powerful caustics, several authorities recommend the 
administration of an anaesthetic. 

The English writers, and those of our own country, seem rather less 
disposed than the French, to make use of powerful escharotics, and lay 
more stress upon the general treatment. Underwood, following M. Dease, 
of Dublin, advises that " the parts should be washed and likewise injected 
with muriatic acid, in chamomile or sage tea, and afterwards dressed 
with the acid, mixed with the honey of roses, and over all a carrot poul- 
tice." Dr. Symonds (Lib. of Tract. Med., vol. iii, p. 23), directs the 
cheek to be frequently rubbed with a stimulating embrocation of cam- 
phorated oil and ammonia, on the first appearance of the swelling, and 
in the intervals to be kept moist with a tepid lotion containing muriate 
of ammonia and alcohol. On the slightest appearance of an eschar upon 
the interior of the mouth, it is to be touched with solid nitrate of silver, 
or strong muriatic acid. If sloughing have already commenced, the ni- 
trate of silver lotion is said to be the best application. The mouth is to 
be frequently washed or syringed with a solution of chloride of soda, and 
when mortification has taken place, we are to endeavor to prevent it from 
spreading, by, carrot or fermenting poultices. Maunsel and Evanson say 
that the early application of muriatic acid, undiluted, or mixed with one 
or two parts of honey, is the only efficient application in these forms of 
gangrene. Dr. Fleming (Dublin Ho sp. Gaz., May 1, 1865), recommends 
the application of a concentrated solution of nitrate of copper, to the 
sloughing surfaces, and also paints the circumference of the disease and 
the surrounding cheek with collodion, which, he believes, acts favorably 
upon the capillary circulation of the part. Dr. Gerhard (Lib. of Pract. 
Med., vol. iii, Am. ed., p. 24), says, "the best local applications are the 
nitrate of silver, if the slough be small in extent ; if much larger, the best 
escharotic is the muriated tincture of iron, applied in the undiluted state : 
after the progress of the disease is arrested, the nicer will improve rapidly 
under an astringent stimulant, such as the tincture of myrrh, or the aro- 
matic wine of the French Pharmacopoeia." Dr. Dunglison (Prac. of 



286 GANGRENE OF THE MOUTH. 

Med., vol. i, p. 36) recommends the application with a brush, of a mixture 
of equal parts of creasote and alcohol, after incisions have been made 
through the gangrenous parts. Dr. Condie (op. cit., 6th eel., p. 174), states 
that he has found a strong solution of sulphate of copper (thirty grains to 
the ounce of water), applied very carefully twice a day, to the full extent 
of the gangrenous ulceration, by far the most successful lotion. 

We have, ourselves, lately employed carbolic acid in two severe cases. 
The pure acid was carefully applied to the sloughing ulcer on the inside 
of the cheek, and subsequently a solution of one part of the acid in fifty 
of water, was frequently employed to wash out the mouth. The applica- 
tion of the undiluted acid seemed to have a beneficial effect, by checking 
the progress of the sloughing, and completely destroying the putridity 
of the dead tissue which had not as 3-et separated. One of the cases recov- 
ered quickly, without perforation of the cheek ; but in the other death 
occurred, with symptoms of profound acbynamia, though there was little, 
if any, extension of the gangrene. 

It seems to us very clear, after the study of the treatment recommended 
by the different writers quoted above, that the most important part of the 
local management of the disease, is the early application of some eschar- 
otic substance to the ulcerations, or to the mortifying parts ; the best is 
probably pure muriatic acid. This should be made use of twice or three 
times a day, observing the precaution to wash the mouth, immediately 
afterwards, with water, by means of a syringe. Later in the disease, 
when it has extended to the skin, the use of escharotics, or of the actual 
cautery, is still recommended by many writers, but opposed by others. 
We confess we should be inclined to prefer, at this stage, the use of mil- 
riated tincture of iron, as recommended by Dr. Gerhard, of carbolic acid 
as used b} T ourselves, of strong lotions of sulphate of copper, of solutions 
of nitrate of silver of moderate strength, or of the dressings of muriatic 
acid and honey of roses, as proposed by Underwood, in connection with 
carrot and fermenting poultices, as recommended by Underwood and 
Symonds. Throughout the course of the disease the mouth ought to be 
frequently cleansed by washing or injecting with solution of chlorinated 
soda, mixed with eight parts of water, or with a dilute solution of carbolic 
acid, which corrects at the same time the terrible fetor of the disease. 

The importance of these measures can scarcely be over-estimated, since 
the presence of gangrenous tissue about the oral cavity must lead to the 
introduction of the poisonous results of putrefaction into the system, 
both by the fetid discharges which partly flow down the oesophagus, and 
still more b}^ the contamination of the inspired air. Indeed, it seems 
quite possible, as urged by Dr. Keiller (Edin. Med. Jour., April, 1862), 
that in cases of unchecked gangrene of the mouth, death occurs, in a 
great measure, from seconclar}^ blood-poisoning, resulting from the con- 
tinued and unavoidable inhalation of air poisoned by emanations from 
the gangrenous sloughs. It is evident, therefore, that local applications, 
both of caustics and antiseptic lotions, must be of great service, by 
arresting the sloughing and correcting or checking the foul discharges. 

General Treatment. — All writers recommend the use of tonics, stim- 



THRUSH. 287 

ulants, and nutritious diet, unless the presence of high fever, or the state 
of the digestive organs, seems to contraindicate their empk^ment. From 
our own personal experience in the treatment of this affection; from a 
consideration of what we have seen most successful in other forms of gan- 
grene, as that following accidents and surgical operations in deteriorated 
constitutions ; from what proved effectual in a case of idiopathic gangrene 
of the vulva, in a child ten years of age, which came under our charge; 
and from what is necessary in that analogous condition of the constitu- 
tion which accompanies t3 T phoid and cachectic diseases ; we are induced to 
believe that the general treatment must be of at least as great importance 
as the local, and that the steady and persevering use of tonics, stimu- 
lants, and of the most strengthening diet, should always be insisted on 
from the earliest period, whether fever be present or not. The quantity 
of stimulants and the amount of food ought, it seems to us, to be meas- 
ured only by the capacity of the digestive organs to receive and assimi- 
late them. Of the tonics, the best are quinine and muriated tincture of 
iron, which may be given in S3 T rup, in doses of a grain of the former with 
from three to five drops of the latter, four or five times a day, to a child 
three or four } r ears old. The most suitable stimulants are very fine old 
brandy, Madeira wine given in considerable quantities, and, if the stom- 
ach is sure to receive it well, carbonate of ammonia, or better still, the 
aromatic spirits of hartshorn. The diet must consist of milk, made into 
punch with brandy, wine-whey, the yolk of eggs beaten up with wine, rich 
soups and beef-tea, animal jellies, and, if the child wish it, tender meat 
finely minced. 

The room in which the child is placed ought to be large, if possible, 
and at all events thoroughly ventilated. 



AKTICLE V. 

THRUSH. 

Definition ; Synonymes ; Frequency ; Forms. — Thrush is associated 
with the growth of a peculiar fungus, the oidium albicans (Robin), and 
appears as a deposit upon the mucous membrane of the mouth of a whitish 
or grayish-yellow exudation, of a soft cheesy consistence, at first adhe- 
rent, and afterwards spontaneously detached, and generally unaccompa- 
nied by ulceration of the tissue beneath. This constitutes the whole dis- 
ease in some cases, no other lesion being discoverable ; whilst in other in- 
stances, and probably in a large majority, it is connected with some more 
or less serious general or local disorder. It is the disease described under 
the title of aphthae or thrush, by Underwood and Eberle ; of aphthae, b} r 
Dewees; of erythematic stomatitis, with curd-like exudation, by Dr. Con- 
die ; and of aphtha lactantium, aphtha lactamen, and aphtha infantilis, 
by the older writers. It is the muguet of the French. 

The frequency of the disease is very great in hospitals for children. It 



288 THRUSH. 

is common also amongst the children of the poor, and comparatively rare 
in the middle and upper classes of society. It occurs under two forms, 
the idiopathic or primary, and symptomatic or secondary. By the first is 
meant the form in which the affection of the mouth is the only perceptible 
lesion ; ~by the second, that in which disease of other organs, or of the 
constitution generally, precedes the buccal exudation. 

Causes. — Predisposing Causes. — The disease occurs at all ages, but 
is hy far most common during the first two months of life. Altered health 
from any cause, deficient ventilation, and icant of cleanliness, strongly 
predispose to the production of thrush. Much difference of opinion ex- 
ists as to the nature of the connection between enteritis and thrush, espe- 
cially since the publication of the researches of M. Yalleix, who thinks 
that the latter disease is almost alwa} T s the consequence of the former, 
and who doubts the existence of purely local cases of thrush. MM. 
Trousseau and Delpech, on the contrary (Journ. de Med. de MM. Beau 
et Trousseau, Januaiy, Februaiy, April, May, 1845), report 14 cases out 
of 58 in which there was neither gastric nor intestinal complication, and 
others in which enteritis did not occur except as a consequence of thrush. 
The} r state, however, that though enteritis does not exist in all cases, and 
is a simple complication in others, it is sometimes the true cause, the sole 
origin of the disease. Again, Dr. Berg, in a very accurate and careful 
history of the disease {Brit, and For. Med. Rev., October, 1847, p. 429), 
in which he asserts and endeavors to show its cryptogamic nature, states 
" that both the local and general S3'mptoms which accompany thrush in 
the child are, in most cases, immediate or secondary consequences of the 
presence of the parasite, and not to be regarded as the causes of that 
fungoid vegetation." It is believed by mauy observers to be contagious. 
This opinion is rendered doubtful, however, b}^ the assertion of MM. 
Baron, Billard, G-uersant, and Yalleix (loc. cit., t. iv, p. 63), that they 
have known children in health to be fed with the same spoon which has 
been used for others affected with the disease, without their contracting 
it. M. Bouchut, on the contrary, and Dr. Berg (loc. cit.), both of whoni 
believe in the cryptogamic nature of thrush, assert it to be contagious. 
Dr. Berg is of opinion that it is " conveyed from one patient to another 
hy sporules or fragments of sporules, in the dried state, floating in the 
atmosphere, but that still more frequently it is propagated by the bottles 
from which children with thrush have been fed, or by the nipple, especi- 
ally where, as in many hospitals, two children are suckled by one nurse." 
This gentleman made many experiments in order to decide this question, 
all of which proved favorable to the idea of contagion. 

Of various predisposing causes which have been cited as productive of 
the disease, the ones most generally admitted are the use of artificial diet, 
particularly one consisting of farinaceous substances, and, in children who 
are suckled, an unhealthy state of the nurse's milk. To show the truth of 
these assertions, I make the following quotations. Underwood saj^s : "A 
principal remote cause of this disease seems to be indigestion, whether 
produced by bad milk, or other unwholesome food, or by the weakness of 
the stomach." Dewees remarks that "children fed much upon farina- 



ANATOMICAL LESIONS. 289 

ceous substances, are especially exposed to the attacks of this disease, 
particularly when their food is sweetened with brown sugar or molasses." 
Dr. Eberle says: "Unwholesome and indigestible nourishment, and over- 
distension of the stomach, during the early stages of infancy, almost in- 
evitably lead to the occurrence of aphtha? (thrash). Bad and old milk, 
and thick farinaceous preparations sweetened with brown sugar or mo- 
lasses, are especially apt to give rise to the disease." Much influence is 
ascribed by Dr. Berg to the operation of artificial food in favoring the 
growth of thrash. M. Yalleix {Joe. cit., p. 60), who has stadied the sub- 
ject with the greatest care and attention sa}~s that amongst the hygienic 
conditions which may act as predisposing causes "one alone has seemed 
to me to exert a. positive influence, and this is improper alimentation. " 
He adds, that since the publication of his Clinique, he has several 
times met with cases of thrush, "and I have alwa} r s found that the chil- 
dren had been put upon feculent diet. On the other hand, I have never 
known a child to have the disease, who had been suckled exclusively 
daring the early months of life." MM. Tronsseau and Delpech, in the 
very valuable paper on muguet (thrush), already quoted, say: " We would 
be justified, therefore, in asserting, that we have never known an infant 
to die of thrash, who had been suckled at a healthy breast, or whose 
health had not been dangerously compromised by other causes." To 
show in another mode the influence of this cause, we will state that of 29 
cases of the disease observed hy these gentlemen in children who were 
suckled, only t, or one-fourth, died ; whilst of 22 in those who were not 
suckled, It, or more than three-fourths, died. Our own experience is 
precisely that of MM. Yalleix, Trousseau, and Delpech. 

Season exerts a considerable influence upon the production of thrush, 
as M. Yalleix found that more than half the cases occurred during the 
three warmest months of the year. 

Exciting causes. — The deprivation of the breast, and a consequent re- 
sort to artificial diet, particularly one consisting of farinaceous substances, 
is probably much the most frequent exciting cause of thrush. An un- 
healthy state of the milk of the nurse will also act as an exciting cause. 
We have met with two cases of the disease, one of them fatal, which ap- 
peared to depend upon the latter circumstance. Dr. Berg believes that 
prolonged sleep from any cause disposes to the disease, by favoring the 
growth of the parasite, or by so changing the secretions of the mucous 
membrane of the mouth, as to render them important agents in augment- 
ing the disorder. An acid state of the buccal secretion is cited as a cause 
by many authors, and is clearly proved to exist in a great many instances. 

Anatomical Lesions. — The characteristic exudation is found upon the 
mucous membrane of the mouth, pharynx, oesophagus, and in rare cases, 
of the stomach and intestines. The question of the possibility of the ex- 
tension of thrash to the gastric mucous membrane has been much dis- 
cussed, and the highest authorities have been almost equally divided upon 
it. This disagreement has arisen solely from the want of microscopical 
examination, which enables the observer to distinguish readily between 
true thrush and other appearances of the gastric mucous membrane 

19 



290 THRUSH. 

which closely resemble it. The most conclusive demonstration of its 
occurrence upon the mucous membrane of the stomach has been recently 
furnished in a valuable article on this subject, b}^ M. J. Parrot, Du Mu- 
guet Gastrique et de quelques autres localisations de ce parasite. Arch, de 
Physiologie Norm, et Path., Xos. 4 and 5, 1869. It is a curious fact, and 
a very important one, insisted upon by MM. Trousseau and Delpech, and 
other observers, that the false membrane never extends to the nasal or 
air-passages ; and they call attention to the singular difference in this 
respect between the affection under consideration and diphtheritic inflam- 
mation, which attacks almost exclusively the nostrils, pharynx, larynx, 
and bronchia. It appears, however, from recent observation, that the 
peculiar growth has been found upon both the epiglottis and the inferior 
vocal cords ; and Parrot (loc. cit.) gives the details of a case in which the 
fungus was found in the air-vesicles of one lung. 

Lesions of the digestive mucous membrane are met with in nearly all 
the cases. M. Talleix states that softening of the gastric mucous mem- 
brane is almost constant, and that it is often accompanied by redness and 
thickening. The authors cited above are of opinion that the gastric 
lesions have been greatly exaggerated, and assert them to be much the 
same as exist in other diseases foreign to the digestive apparatus. Va- 
rious morbid alterations of the mucous membrane of the intestines exist 
in nearly all fatal cases. This fact is acknowledged as well by MM. 
Trousseau and Delpech, who deny the invariable connection of these al- 
terations with thrush, as hy M. Valleix, who asserts the connection almost 
without reserve. In nearly all cases the mucous membrane of the large 
intestine presents some of the following lesions, which are mentioned in 
the order of their frequency: thickening, injection, softening, or ulcera- 
tion. In the ileum are found, in a great many cases, injection, softening, 
or thickening of the mucous membrane, unusual development of the 
mucous follicles, and tumefaction and ulceration of the glands of Pe}^er. 

In severe sjmiptomatic cases a certain amount of erythematous inflam- 
mation is commonly found upon the skin of the buttocks and thighs, and 
ulcerations sometimes exist upon the inner ankles. Traces of inflamma- 
tion sometimes, but very rarely, exist in the membranes of the brain, and 
the lungs not unfrequentty present the lesions of secondarj' pneumonia. 
Before leaving this part of the subject, we may remark that in the few 
cases we have met with in private practice, no ulcerations occurred upon 
the malleoli, and the erythema was observed only in the neighborhood of 
the anus. 

Dr. Dewees describes the autopsy of a child who died about the end of 
the first month of life, of what he designates as aphthae. The lesions 
coincide so closely with those which are characteristic of thrush, that we 
will quote the description, in order that the two may be compared to- 
gether by the reader. " We found the whole tract of the oesophagus lit- 
erally blocked up with an aphthous incrustation, to the cardia, and there 
it suddenly stopped. The inner coat of the stomach bore some marks of 
inflammation, as did several portions of the intestines ; but not a trace of 
.aphthae could be discovered below the place just mentioned." In the 



SYMPTOMS. 291 

previous description of the case, he sa t ys that coat after coat of aphthae 
were thrown off, and each new crop appeared to be more abundant, and 
less amenable to remedies. (Dewees on Children, p. 304-305.) 

Dr. Eberle sa}*s : "I have myself had an opportunity of examining the 
bod}* of an infant, that had died of this disease (aphthae or thrush). In 
this case the aphtha? were very distinct, throughout the whole course of 
the oesophagus. The stomach and bowels presented nothing that bore any 
resemblance to this eruption; but there were decided marks of inflamma- 
tion in the mucous membrane of the small intestines, with a vast number 
of minute superficial ulcerations, and larger patches of softening of this 
tissue, throughout the colon and lower part of the rectum." (Diseases of 
Children, p. 1T2-1T3.) 

Symptoms. — We shall first describe the characters of the exudation, 
and then proceed to the consideration of certain general and local phe- 
nomena which exist to a greater or less extent in both forms of the 
disease. 

The mucous membrane of the mouth is often somewhat red, dry, and 
tender for a longer or a shorter time (generally from one to three days), 
before the appearance of the exudation, and at the same time the papillae 
of the tongue swell and become protuberant. Next the exudation shows 
itself in the form of small, whitish points, sometimes on the tongue first, 
and in other cases on the inside of the lips, whence it extends to the 
cheeks in idiopathic mild cases, and to the roof of the mouth, soft palate, 
phaiynx, and oesophagus, in the grave symptomatic form. The points of 
false membrane first deposited rapidly increase in size and thickness, so 
that in from one to three or four days, they assume the form of large 
patches, or a continuous membrane, which covers the whole or a con- 
siderable portion of the cavity of the mouth. When the exudation is 
recent, it is thin, and its surface smooth; when, on the contrary, it has 
been longer deposited, it becomes thicker, and its surface is rough. It 
is at first of a milk-white or pearly hue, but when undisturbed assumes a 
grayish or yellowish color. It is soft in consistence, breaking down under 
the finger like cheese, and presenting no traces of organization to the 
naked eye. It adheres to the mucous membrane with considerable te- 
nacity at first, but becomes looser after awhile, and is detached sponta- 
neously at last without any lesion of the tissue beneath. 

The foregoing description applies to the exudation as it appears to the 
unassisted eye. We pass next to give an account of the characters it 
presents, when subjected to microscopical examination, and in so doing- 
shall quote the language of Berg, who first discovered that thrush essen- 
tially depended upon the presence of a peculiar parasitic fungus, to which 
Robin has given the name of oidium albicans. Dr. Berg (loc. ciL) states, 
that the white coating of the exudation consists of epithelium, thickened 
by the swelling of its constituent cells ; from the epithelium there springs 
a parasitic fungus in greater or less quantity, so that the chief portion of 
a patch of aphthae (thrush) is composed either of epithelium or else of the 
parasitic growth. Under a magnifying power of from 200 to 300 diam- 
eters, an aphthous crust is seen to consist of epithelial cells, with a more 



292 THEUSH. 

or less interwoven coat of fibres, and a variable number of spherical or 
oval cells, without any sign of exudation-corpuscles, but only a small 
quantity of molecular albuminous deposit. " We can often trace the 
successive development of these cells from a spherical one of the smallest 
size, to an oval cell, and thence to a filament; and we have no doubt our- 
selves that the smaller cells are sporules, out of whose development the 
larger oval cells are formed, and finally, the filaments in the same man- 
ner as has been observed in other fungoid growths of this nature." 
Numerous projecting fibrils are observed in the circumference of an 
aphthous crust when submitted to the microscope; but these are ren- 
dered infinitely more clear by a weak solution of potash, which dissolves 
the albumen, and renders the cells of the epithelium transparent, while, 
at the same time, it diminishes their intimate cohesion, and the network 
of vegetable fibres is more plainly seen. " These fibres are cylindrical, 
with sharply defined dark edges, and their centres are transparent in 
transmitted light; they are generally equal in thickness, but at times 
they are, as it were, knotted together, and divided by distinct walls of 

separation In their interior, these fibrils often exhibit nucleated 

cells ; occasionally these are very numerous, and of small size, but at times 
they are larger. In their course the fibrils divide into numerous branches, 
whose diameter is not less than that of the original stem, and I have occa- 
sionally observed these ramifications to increase in thickness, at their 
free extremity, and to terminate in a club-shaped end with a species of 
cell. From the sides of the fibrils spring numerous sporules, forming 

a point of departure for new ramifications Careful investigation 

has shown us that these cells are placed upon the sides of the fibrils, and 
in particular that they are congregated around the terminations of the 
latter. It must, therefore, be admitted that the cells and the fibrils are both 
constituent parts of one and the same organization. When this growth 
vegetates undisturbed, its fibrils penetrate between the layers of the epi- 
thelial cells, but do not extend deeper than the inferior layer, though they 
spread laterally in every direction. On the free surface of the epithelium, 
the ramifications rise above the surface, exhibiting at the same time an 
abundant fructification, which gives a yellowish hue to the exterior." 

M. Parrot, in describing the appearances of thrush upon the gastric 
mucous membrane, states that the disease presented itself in the form of 
small prominent rounded masses, of yellowish color, and either isolated 
or in groups. These were adherent to the mucous membrane, nearly all 
umbilicated, and upon pressure the central depression became filled with 
a chees3^-looking material. On microscopic examination of sections, the 
spores and filaments of the muguet were found infiltrating the tissue, 
and as it were planted there, at times scattered in small numbers, at 
others accumulated in large masses, and holding between them manj T oil- 
drops and some debris of the mucous membrane. The muscular coat of 
the stomach was not involved, but in some instances the spores and fila- 
ments penetrated the mucous membrane, and extended to the submucous 
space. In other cases, the mucous membrane was only superficially in- 
volved. 



SYMPTOMS. 293 

The reader is referred for a more full account of the cryptogamic theory 
of thrush to the interesting review of Berg's work above quoted, and to 
Bouehut's work on the diseases of new-born children; and for a complete 
description of the oidium albicans to the work of Robin, Histoire Natu- 
relle des Vegetaux Parasites, Paris, 1853; the articles of Parrot above 
quoted; and the article on Thrush in Yogel's work on the Diseases of 
Children (Arner. ed., 18T0, p. 99). 

Symptoms of the Mild Form of TJirush. — This form is the one most 
frequently met with in private practice. It is mild in all its characters, 
and often presents no other symptoms than those connected with the 
mouth. These are heat and dryness, with tenderness of that part. The 
tenderness is shown by the child's crying and jerking the head back- 
wards when the finger is introduced into the mouth, whereas, in health, 
the infant will almost always seize the finger and suck it with consider- 
able force. It is shown, also, by the refusal to take the breast, or by the 
difficulty with which this is done, the child occasionally letting the nipple 
drop with a cry of pain, then seizing it again, and again dropping it with 
fretting or screaming. In some of the cases there are various signs of 
disorder of the digestive tube, which are, however, seldom severe. They 
consist of slight diarrhoea, the stools being at first yellow, and afterwards 
green and acid; of occasional vomiting, of attacks of colicky pain, and 
sometimes of feverishness. To show how frequent is the occurrence of 
diarrhoea in thrush, and to prove also that it is not a necessary accom- 
paniment of the disease, as has been supposed by some persons, we will 
quote the fact mentioned by Dr. Berg, that of 115 cases, in only 29 did 
the stools retain the normal yellow color throughout the whole course of 
the disease; while in the remaining 86, green evacuations appeared simul- 
taneously with the invasion, or supervened at a later period. We may 
cite also the cases reported b}^ MM. Trousseau and Delpech, of which 
only 14 out of 58 presented neither gastric nor intestinal complications. 

The amount of exudation is generally small in this form, and it rarely 
extends behind the soft palate. The duration is usually between four 
and nineteen days, the average being about eight or twelve. The termi- 
nation is almost always favorable. 

Grave Form. — It is under this form that the disease is most apt to 
occur in public institutions for children, and particularly in foundling hos- 
pitals. That it sometimes occurs, also, in private practice, will not be 
doubted, we think, by any who will read with care the descriptions of the 
disease given by Underwood, Dewees, and Eberle. We have ourselves 
met with two fatal cases in private practice, which presented all the sjmip- 
toms described by M, Yalleix as characterizing those observed by him in 
the Foundling's Hospital at Paris, with the single exception of the ulcera- 
tions upon the internal malleoli. They were both children of parents who 
had every comfort at their command. One died at the age of four weeks, 
in consequence of the attempt to rear it on artificial diet. The other per- 
ished when six weeks old, apparently from some unhealthy condition of 
the mother's milk, which seems the more probable from the fact that the 
same mother had previously lost two children under precisely similar cir- 



294 THRUSH. 

cnmstances ; all the children of this person were born vigorous and hearty, 
and did well for a short time, but soon after the birth, the nipples of the 
mother became dreadfully excoriated, the digestive organs of the infant 
began to give way, and death finally occurred with all the S3 r mptoms of 
fully-developed thrush. We can surmise now, though no examination 
was made at the time, that the cause of the disease was a continuance of 
colostrum corpuscles in the mother's milk. 

The most important symptoms of the grave form are the buccal exuda- 
tion, various abdominal s3'mptoms, particularly diarrhoea, vomiting, and 
colic, and more or less marked fever. The order of succession of the 
symptoms in severe thrush is not always the same. In most of the cases 
the first symptom observed is, probably, diarrhoea, which is soon followed 
by fever, and in a few days by the appearance of the false membrane in 
the mouth. In a smaller number of instances the buccal exudation is the 
first symptom observed. The characters of the exudation are much the 
same as those observed in the mild form of the disease, except that the 
membrane is thicker, covers a larger portion of the mouth, and generally 
extends to the phaiynx and oesophagus. In addition to the plastic de- 
posit, there sometimes exist, especially in very bad cases, ulcerations upon 
the roof of the mouth, frpenum linguae, and gums. These are generally 
few in number, and either confined to the mucous tissue, or they may 
extend to the fibrous texture beneath ; the surface upon which they rest 
is generally softened in consistence ; their edges are irregular, soft, and 
of a whitish or reddish color. The heat of the mouth is not generally 
increased, except in veiy severe cases ; the mouth is moist at first, but 
afterwards becomes veiy dry, and, from the refusal to suck the finger 
when it is introduced between the lips, and the difficulty with which 
the acts of suckling or feeding are performed, is evidently tender and 
painful. 

The symptoms depending on the euteritic affection, are tenderness of 
the abdomen, diarrhoea, vomiting, and fever. The abdomen is usually 
distended by flatulent collections in the bowels, and is more or less pain- 
ful to the touch, particularly in the right iliac fossa and epigastrium, and 
in severe cases over its whole extent. At the same time the child evi- 
dently suffers from colicky pains, as shown by restlessness, by uneasy, 
twisting movements of the trunk, by kicking of the limbs, and by crying, 
particularly just before or at the moment of the evacuations. The appe- 
tite is usually diminished or entirely lost. The diarrhoea comes on gradu- 
ally, the stools retaining their natural color at first, and being merely 
thinner and more frequent than natural. As the case progresses, they 
become more and more liquid and numerous, and almost invariably of a 
bright green color, and very acid. The green color of the discharges, 
and their highly acid condition, is noticed by all observers. Vomiting 
occurs in man}" of the cases, but is less frequent than diarrhoea. In some 
instances it is very obstinate and distressing, causing the rejection of 
whatever alimentary substances the child may take. Under these cir- 
cumstances it has often been observed to coincide with the presence of 
a great deal of exudation upon the base of the tongue and soft palate, 



SYMPTOMS. 295 

which has been supposed to act as its exciting cause. In other instances 
it is not so frequent, and as the matters ejected consist of greenish or 
yellowish bile, while, at the same time, the epigastrium is very sensible 
to pressure, this form of vomiting has been thought to depend upon 
gastritis. 

Fever exists in most cases, from the time that diarrhoea makes its ap- 
pearance, and sometimes at an earlier period. It is at first moderate, 
but as the case goes on, often becomes intense, the pulse rising gradually 
from 80 to 90, or 120, 140, and even 160. The heat of the surface, espe- 
cially of the abdomen, is much increased, and accompanied by dryness. 
The feverish condition of the sj'stem is shown also by the restlessness 
and fretting of the child, and often by loud, frequent crying. When the 
exudation extends into the pharynx, the cr} r usually becomes hoarse and 
indistinct. 

There are two other sj'mptoms which occur in the course of thrush, 
about which some discussion has arisen. These are the appearance of 
an erythematous redness about the anus, and upon the buttocks, genitals, 
and upper parts of the thighs, and ulcerations upon the internal malleoli. 
The erythema is stated by M. Yalleix to precede the other symptoms in 
the greater number of instances, whilst MM. Trousseau and Delpech deny 
the correctness of the assertion, and observed it to follow the diarrhoea 
in the majority of their cases. It seems to us that the latter authors are 
correct in ascribing the erythema to the irritation produced by the con- 
tact of the urine with the skin, which is predisposed, by the cachectic 
state of the constitution, to take on inflammation from causes which would 
not affect it in a healthy subject. The eiythema is sometimes followed 
by papules, vesicles, blebs, and ulcerations, all of which probably depend 
upon the cause just referred to. The malleolar ulcerations are ascribed 
to the friction of the ankles against each other, a cause sufficient to pro- 
duce such an effect in a broken-down, diseased constitution, though in- 
sufficient in a healthy one. We may mention that we have seen the ery- 
thema frequently in private practice, but never the malleolar ulcerations. 

During the acute period of the disease, the strength of the child is not 
much diminished, but as the case approaches its termination, if no favor- 
able change takes place, the patient becomes weak and exhausted ; the 
face assumes a pale and sallow look ; the features are sharp and defined, 
and the eyes dull and surrounded by bluish circles. At the same time the 
whole body become emaciated, the skin loses its elasticity, and hangs in 
folds or wrinkles upon the limbs, and the surface assumes a dark and 
dingy hue. As the fatal termination approaches, all restlessness ceases, 
and the child lies profoundly still, or only moves the mouth from time to 
time, or utters a faint cry ; the diarrhoea diminishes, and the vomiting 
generally ceases ; the pulse becomes very rapid and weak, the extremities 
cold, and death occurs in the midst of profound quiet, or after a few slight 
convulsive movements. The duration of this form of the disease is very 
uncertain. It is often less than that of the mild form, since many children 
die in the first five days after the appearance of the exudation. In other 



296 THRUSH. 

cases it is much longer, from a few weeks to two months. Relapses are 
not uncommon. 

Before closing our remarks upon the symptoms, it is proper to state 
that the disease sometimes occurs at the termination of acute local affec- 
tions, as pneumonia, bronchitis, or pleurisy, under which circumstances, 
there will be, in addition to the symptoms peculiar to thrush, those of the 
malady which preceded it. 

Xature op the Disease. — Repeated microscopic examinations have 
so uniformly confirmed the statements of Grub}'' and Berg, that it is no 
longer doubtful that a peculiar parasite, oidium albicans, is a constant 
element in the exudation of thrush. It is, however, far from being so 
well determined what relation this growth bears to the disease ; since, 
while one class of authorities consider it the essential and sole cause of 
the other local and general symptoms, another regard it merely as an 
epiphenomenon, the spores of the parasite finding a suitable nidus for 
development on the already diseased mucous membrane. Fortunately, 
the solution of this question is of no veiy great practical importance, as 
the causes of the disease are well ascertained, and its proplrylactic and 
curative treatment will not be affected by the view entertained. 

Diagnosis. — The diagnosis of thrush is rarely difficult. Aphthae differ 
from it in their vesicular nature during the formative stage, in the ulcera- 
tions which follow the vesicles, and in the absence of false membranes. 
From ulcero-membranous stomatitis it may be distinguished, by the 
formation in that disease of false membrane in laj^ers from the beginning ; 
by the presence of ulcerations ; by the spongy, bleeding state of the gums ; 
by the fetid breath ; by the absence of the abdominal sjmiptoms which 
exist in thrush ; and by the microscopic appeea*ances of the deposit. 

Prognosis. — The prognosis must depend, in great measure, upon the 
circumstances under which the disease occurs. In private practice, and 
whenever the patients are suckled b}^ their own mothers, or by healthy 
nurses, it is a mild affection. But in foundling hospitals, on the contrary, 
where the children are mostly brought up by hand, it is one of the most 
fatal maladies to which children are subject. The prognosis varies ac- 
cording to the form of the disease. The mild form is rarely fatal, while 
the grave form is fatal in the great majority of the cases. 

To show the frightful severity of the disease under certain circum- 
stances, we may mention that of 140 cases which occurred in the wards 
of M. Baron, at the Foundling's Hospital of Paris, only 29 recovered ; 
while of 22 cases observed by M. Yalleix, in the same hospital, but 2 re- 
covered (Yalleix, loc. czY., p. 74). Again, M. Bouchut states that of 42 
cases observed by himself, at the Necker Hospital, 14 were of the idio- 
pathic (mild) form, all of which terminated favorably ; and 28 of the 
grave or sjmiptomatic form, of which 20 died, and 8 left the hospital still 
laboring under the disease. Of the 20 fatal cases, 12 presented the lesions 
of chronic entero-colitis, 4 of acute entero-colitis, 8 of pneumonia, and 1 
of hydrocephalus. It ma}' be stated, in conclusion, that the danger is 
greatest, in private practice, when the attack occurs in a child fed on artifi- 
cial diet ; when there is reason to suspect an unhealthy state of the nurse's 



GENERAL TREATMENT. 297 

milk ; and in proportion to the extent and quantity of the exudation, its 
resistance to treatment, and the severity and obstinacy of the abdominal 
symptoms. 

Treatment. — Prophylactic Treatment. — The most certain means of 
preventing thrush are evidently to procure for the child a full, healthy 
breast of milk, to give it a good habitation, to secure for it perfect clean- 
liness, and to attend properly to its clothing. When it is impossible, 
from any cause, to obtain a nurse for the child, the diet ought to be most 
carefully regulated as to quality, quantity, and times of administration. 
Careful attention to these points will, and, we doubt not, have, greatly 
diminished the number and lessened the severity of the disease in pri- 
vate practice. 

General Treatment. — It is clear that the successful management of 
thrush must depend much more upon judicious regulation of the hygiene 
of the child, than upon any therapeutical system that can be devised. 
The most frequent cause of the disease is, as we have seen, artificial diet, 
especially one in which milk is sparingly used or excluded, or an un- 
healthy state of the nurse's milk. It is reasonable to conclude, therefore, 
that attention to the removal or mitigation of these and other unfavor- 
able hygienic conditions, constitutes the most important indication of 
treatment. 

If a child who has been attacked with thrush is suckled exclusively, 
the milk of the nurse ought to be subjected to chemical and microscopic 
examination ; and should it be found to present unhealthy characters, 
another nurse ought to be procured as soon as possible. In all such cases 
the nurse must pay strict attention to her diet, avoiding all articles which 
she knows or suspects to disagree with her, and all very rich dishes. 
Dewees recommends that she should abstain from most common vegeta- 
bles, except rice, and from all kinds of liquors, especially the fermented. 

When the disease occurs in a child who is nursed and fed alternately, 
and the remark about to be made applies still more appropriately to one 
fed entirely upon artificial diet, the most important remedy in the case is 
to procure a good wet-nurse. This is far better than any medical treat- 
ment that can be instituted. Often, however, this is impossible, and, 
under such circumstances, the regulation of the diet ought to be attended 
to with the utmost care by the physician himself, who should specify its 
material, quantity, and mode of preparation. 

As we shall be obliged constantly to refer to the proper diet for young 
children in our future articles on diseases of the digestive organs, and 
indeed all through this work, we think it will be best to make some gene- 
ral and extended remarks on the subject here, where we first meet with a 
disease, the cause of which is almost always improper food, and the cure 
of which is the abandonment of a faulty, and the substitution of a proper 
aliment. 

In the first place, we wish to repeat the statement already made, that 
the breast gives the only food for infants which can be relied on as the 
correct one. This may seem very much like saying that white is white, 
and red is red, or that two and two do indubitably make four; indeed, 



298 THRUSH. 

to ourselves it seems utterly superfluous, but we have known so many 
medical men, men in authority in the nursery, and such hosts of fathers 
and mothers, who cannot be made to believe this, that we feel compelled 
to reiterate our own individual opinions as strongly as possible. But 
cases do constantly occur in which a 3 T oung infant must be wholly or in 
part fed artificially, and here we have to recommend some substitute for 
breast-milk. In this city, asses' milk, which is conceded to be more like 
human milk than that of any other animal, cannot be had, and we are 
forced to take cow's or goat's milk. The latter is not so common as to be 
readily obtained, and practically we are driven to the use of the former. 

In choosing cow's milk, the first thing to be thought of is the purity 
of the milk. In small towns and in the country it is very easy to obtain 
fresh pure milk, but in large cities it is often very difficult. Still, with 
due care and diligence, and mone} T , it can generally be done. Our own 
practice has always been to choose a milkman who himself brings milk 
from a farm, or who, at least, employs himself the man who delivers it. 
We never have, and never shall, so long as we can help ourselves, take 
milk from those middle-men who buy it of anybody that may have it to 
sell. Moreover, the person who has charge of the child should always, 
if possible, know the milkman personally, and know exactly where he 
comes from, and what manner of man he maj be. An honest farmer or 
dairyman who pastures and feeds his own cows on a healthy farm, is the 
man to be emploj^ed to furnish milk to the poor little baby who has to 
seek another dairy than his own mother's. If the character of the milk- 
man is not a sufficient guarantee, or if, from any accident, the milk has 
to be changed, or if any doubt arises as to its quality, there are some 
simple methods of judging which can be made use of by any person of 
ordinary intelligence, and which will reveal any gross deception on the 
part of the milk vender. 

A good specimen of cow's milk ought to be slightly acid or neutral; it 
should contain a certain average proportion of cream, and it should have 
a certain average density. 

These points may be ascertained with sufficient accuracy to guide us 
in our choice or refusal of any sample of milk, in the following mode. 
Litmus paper turns red when touched by any acid ; a very weak acid will 
do this. If a good specimen of litmus paper (which can be procured of 
the apothecary) turns faintly red, when dipped into milk, the milk is 
properly acid ; if turned bright reel, the milk is too acid. When no 
change is produced on the litmus paper, the milk is either neutral (which 
is sometimes the case with kealtlry milk), or it is alkaline. To determine 
whether it be neutral, turmeric paper, which is turned brown b}' r alkaline 
solutions, must be used. If the specimen is found to be alkaline in a 
marked degree, either the cow is diseased in all probability, or some alkali 
has been added to the milk. 

It is a curious fact, that Dr. Parkes (Manual of Practical Hygiene, 2d 
ed., London, 1866), is almost alone in asserting that healthy cow's milk 
is either faintly acid or neutral. Most authorities assert that it is alka- 
line. In order to determine this matter for ourselves, we tested the milk 



MODE OF TESTING MILK. 299 

of thirty-one fine cows, fed on the finest pasturage in the neighborhood of 
this city. This was done by taking the milk, just as it was drawn from 
each animal, separately in the milking-house, and testing at once with. 
the best litmus paper. In all the paper was turned red, more or less dis- 
tinctly. Dr. John Ashhurst, of this city, tested for us with both lit- 
mus and turmeric paper, the milk of nine fine Durham and of four Alder- 
ney cows, belonging to his father, all on the finest pasturage. He says 
that in one Durham and in one Aldernejr the milk appears to have been 
almost neutral, and in all the rest more or less acid. In testing the milk 
of another Durham, litmus paper was reddened, whilst the turmeric was 
also slightly changed, but he supposed the latter change to be due to a 
greasy condition of the milk, owing to the fact that the cow was in the 
latter period of a long lactation. 

To determine the proportion of cream, we may make use of a glass 
vessel, made of a section of a C3'linder, tall, and not too wide, and grad- 
uated to inches, with the upper inch divided into hundredths, or a French 
glass divided into centimetres, such as may be found in the shops for the 
sale of chemical apparatus. This is to be filled to the upper mark with 
milk, and put aside for twenty-four hours ; at the end of that time the 
cream will have separated, and risen to the top, and its proportion can 
be read off on the graduated scale. According to Dr. Parkes, the cream 
should be from 4 to 6 per cent. In the milk of Alderney cows, it will 
reach 30 per cent, to 40 per cent. This seems to us too large a propor- 
tion for the use of children. 

We think, however, that the average of cream given by Dr. Parkes is 
probablj' rather too low. The liaison Rustique, a French work of very 
high authority on agriculture, states (tome iii, p. 61), that the milk of 
cows, of good race, well kept, furnishes 15 per cent, of cream. The milk 
supplied b} T the milkman, employed by one of us, gave 14 per cent, of 
cream on one occasion, and 10 at another. The specific gravity of the 
former specimen was found to be 1029. Of three other specimens, bought 
at hazard, of different dealers, the proportion of cream was 7 per cent., 6 
per cent., and 14 per cent., respectively. We are disposed to think, there- 
fore, that families ought to endeavor to procure milk containing at least 
10 per cent, of cream. 

We next have to ascertain the density, in order to determine the pro- 
portion of water. The most common adulteration of milk is, of course, 
with water, to increase its quantity, and so augment the profits of the 
salesman. The density or specific gravity, let it be remembered, is no 
safe guide as to the proportion of cream. That must be settled in the 
mode just described. But the density gives the proportion of water. 
The specific gravity of good, pure milk, is given by Dr. Parkes at 1030.5, 
or 1026, at a temperature of 60° Fahr. We found it in an excellent spe- 
cimen to be 1029. Dr. Parkes found that when, in milk of the specific 
gravity above mentioned, one part of water was added to nine of milk, 
the specific gravity fell to 1027 or 1023 ; when three parts of water were 
added to seven of milk, it fell to 1021, or 1017.5; and when five parts 



300 THRUSH. 

of water to five of milk, it fell to 1015. These were the proportions ob- 
tained b3' several experiments. 

TVe found that the specific gravity of a specimen of excellent milk, as 
ascertained Iry a hydrometer, was 1028. When to this milk was added 
one-fourth part of water, the specific gravity fell to ] 024, and when a 
half had been added it fell to 1020. In another specimen, the specific 
gravity, obtained in the same way, was 1030 at a temperature of 61 c Fahr. 
When to this specimen one-half water was added, the specific gravity fell 
to 1020. 

By these three simple methods of examination, the acidity or alkalinity 
of the milk, the proportion of cream, and the proportion of water can be 
determined. If the milk is either strongly acid or alkaline, it is not to 
be trusted. If it be strongly acid, it has undergone the acid fermentation, 
and is not fit for use. If it be strongly alkaline, it has either been adul- 
terated by the addition of an alkali, probably, according to Dr. Parkes, 
carbonate of soda, to prevent or arrest the lactic acid fermentation, or it 
maj' have been taken from a diseased cow. Dr. Parkes suggests the 
latter probability in a doubtful way. Dr. J. F. Simon, of Berlin (Ani- 
mal Chemistry with Reference to the Physiology and Pathology of Man, 
vol. ii, p. 6T), states, that he analyzed milk drawn from the teat of a cow 
having vaccinia, and found it strongly alkaline, and showing with the 
microscope mucous and pus corpuscles, while that drawn from a healthy 
teat had a mild acid reaction, and contained no pus or mucous corpus- 
cles. He also states (page 68), that Herberger has analyzed the milk 
of cows suffering from the grease, and found it to contain an increased 
quantity of the alkaline salts, in the first stage ; in the second stage it 
was thick and viscid, and had, besides, an unpleasant and putrid taste 
and smell. In both stages, the presence of carbonate of ammonia (an 
ingredient never before observed in the milk) was detected. 

The most common adulteration of milk is with water. The mode of 
detecting this, by ascertaining the specific gravity, has already been 
given. Starch is sometimes used to thicken a thin milk. The micro- 
scope will detect this by showing the presence of the starch granules. 

The mother will often wish to preserve milk, especially in our hot sum- 
mer weather, or for a few days, when on a journey. The best preserva- 
tive in hot weather, for the day, is of course a good ice-chest. Dr. Parkes 
says that when boiled, "the bottle quite filled, and at once corked up and 
well sealed, the milk lessens in bulk, and a vacuum is formed above. It 
will keep thus for some time. A little sugar aids the preservation. If the 
heat is carried in a close vessel to 250 c Fahr., the milk is preserved for a 
very long time, even for years ; the butter ma} T separate, but this is of no 
consequence ;" or, if a little carbonate of soda and sugar is added, with- 
out boiling, he says it will keep for ten days or a fortnight. Cooley, in 
his Cyclopaedia of Practical Receipts, states, that the addition of ten to 
twelve grains of carbonate, or bicarbonate of soda, to each pint of milk, 
will preserve it for eight or ten days in temperate weather, and adds that 
this addition is harmless, and, indeed, is advantageous to dyspeptic pa- 



MODE OF PREPARING MILK, AND QUANTITY TO BE TAKEN. 301 

tients. The method of boiling, proposed by Dr. Parkes, is the one now 
so much used for preserving fruits fresh. 

Having determined upon the use of cow's milk, we have next to con- 
sider its mode of preparation. 

It should never be given pure to young infants, at least such is our 
clear conviction. TTe still believe that the old rule, of two parts of water 
to one of milk, is the proper one during the first month. We know that 
some of the more recent writers, and not a few of the plrysicians of this 
city, now order half water and half milk, aud some children do well on 
that proportion ; but we still believe that when the milk is of full average 
richness (containing ten or fifteen per cent, of cream, and having a spe- 
cific gravity of 1028 to 1030), the old rule of two-thirds water is safest. 
And this is certainly true of all sickly children within the month. It is 
easy to increase the proportion afterwards, if the child does not develop 
as it ought ; but the stomach once seriously deranged and overloaded by 
too rich a food, a severe and even a lingering illness may be the penalty 
the child will have to sutler. 

When the child comes to be one or two months of age, the proportion 
may be increased to one-half, with care ; always, however, returning to 
the first rule, should the child exhibit signs of gastric disturbance, or 
should the stools contain man}^ whitish lumps, consisting of undigested 
caseine. At the age of five or six months the proportion may be made two- 
thirds milk, and thus, gradually, the milk may be given pure, though we 
have seen many children who, even at a year of age, did better with a 
moderate dilution than with the pure fluid. 

The quantity of food to be given each clay, is a very important consid- 
eration, and one about which less is usually said than the matter deserves. 
In the first edition of this work, published in 1848, it was stated that, 
from various inquiries and observations, we were led to believe that a 
healthy infant of two or three weeks old, would receive, from a good 
nurse, and digest well, about a pint of food in twenty-four hours, and 
that \>j the end of the first, and in the second month, the quantity taken 
by the child increased to a pint and a half or a quart. Some of the data 
upon which these assertions were based were the following: A woman, 
attended in her confinement by one of us, had a pint of milk drawn, by 
the nurse, daily from the breasts, in addition to what the child took. 
On asking the nurse how much she supposed the child — a vigorous, 
hearty boy — took at the same time, her reply was that, judging from 
the frequency and vigor with which he nursed, she supposed he took as 
much as was drawn from the breasts. Another patient lost her child at 
birth, and desiring to go out as a wet-nurse, kept up the flow of her 
milk by using a puppy. Six weeks after her confinement, a good breast- 
pump was given her, and she was desired to keep all the milk she could 
obtain in twenty-four hours. The quantity measured exactly a quart. 

It was also stated, in that edition, that careful inquiries were made, in 
regard to this matter, of one of the most experienced and intelligent 
monthly nurses we ever knew. She was desired to answer accurately the 
two following questions : 



302 THRUSH. 

1. How much milk do you think a healthy mother gives to her child 
dairy, after the flow is fairly established ? 

2. What quantity of nourishment do you give in twenty-four hours, 
to infants you are compelled to feed exclusively? 

The reply to the first question was, that she had often drawn more than a 
pint from the breasts in the twenty-four hours, in addition to what a healthy 
child took, and that she had frequently taken as much as three pints from 
women who had lost their children. She supposed, therefore, that a 
hearty child would take, during the first two weeks, at least a pint, and 
much more afterwards. 

To the second question she replied, that she usually gave to hearty 
children of one, two, and three weeks old, a pint of food in twenty-four 
hours. 

It was stated in the first edition of this work that, judging from the 
above data, a young infant ought to take at least a pint of nourishment 
in the twenty-four hours. Our experience, since that time, has convinced 
us that, if anything, this estimate is rather too low than too high. Now 
we should say that, in the first ten days after birth, a pint or a little over 
is about the right quantity. After that period a pint and a half to a quart 
is probably the proper amount up to the second month. In the second 
and third months many children require a full quart, and some three 
pints ; though, after all, we must be ruled very much by the instinctive 
wants of the individual child. When fed at regular intervals, upon food 
of the proper strength, we do not think children often take more than they 
need. 

In the first month the child ought to be fed every two hours, if it takes 
the food well. After the first month, once in three hours is usually the 
best rule. Feeding the child once in three hours, between six in the 
morning and six in the evening, and twice in the night, would give six 
meals in the twenty-four hours. If six ounces (a gill and a half) be given 
each time, the child would get thirty-six ounces, which is a little over a 
quart. As the age increases, eight ounces may be given every four hours, 
which would make a quart and a half; and we have met with very few 
children who exceed this, particularly as by this time the food consists 
of two-thirds or three-fourths milk, or even pure milk. It may seem 
needless to acid that, unless the child is taking decidedly less than the 
average stated above, it ought not to be in any degree forced or enticed 
to swallow more than it takes willingly. The moment it has had enough, 
the nurse ought to cease to offer any more. 

As this matter of the quantity of artificial food necessary for the develop- 
ment of the child is a very important one, and as it is a point which has 
not been very clearly defined by most writers, we have thought it well to 
lay before our readers the following calculation of what infants may need, 
from the estimate made by Dr. Parkes as to the amount of food necessary 
for adults. 

According to that author, an adult of average size and activit}^ will, 
under conditions of moderate exertion, take in twenty-four hours from 
5 ] g th to ^ th of his own weight in solid and liquid food. The relative 



QUANTITY OF FOOD NEEDED BY CHILDREN. 303 

proportion of the so-called solid and liquid food varies greatly, but is 
usually about 40 oz. avoirdupois of the former, and 60 oz. of water. As, 
however, all the so-called solid food — bread, meat, &c. — contains a cer- 
tain amount of water, the actual average amount of water-free food taken 
by an adult, weighing 150 lbs., is 23 oz., or T J g th of the weight of the 
body; and the amount of water about 15 oz. Or, in other words, every 
pound weight of the body receives about 0.15 oz. of water-free food and 
0.5 oz. of water in twenty-four hours. This water-free food is composed 
as follows, according to Moleschott: 

oz. avoirdupois = 437.5 gr. 

Albuminous substances, . . . 4.587 

Fatty " .... 2.964 

Carbo-hydrates, 14.257 

Salts (of all kinds), .... 1.058 

22.866 

On the basis of these calculations, an infant at birth, the average 
weight being 7 lbs., would require 1.05 oz. of water-free food ; and a child 
weighing 20 lbs., which is probably the average weight of healthy chil- 
dren of five to six months old, would require 3 oz. 

Assuming the total solid of cow's milk to be 10 per cent., which is 
rather less than the average as given by Becquerel and Rodier (see com- 
position of health}'' milk), it would require to yield an ounce of water- 
free food rather more than 1 ounces of milk. 

Thus on this supposition (i. e., that the total solids of cow's milk of 
sp. gr. 1026, equal 10 per cent.) one pint imperial (20 oz.) will contain in 
round numbers, 



Caseine, 


. 262 grains. 


Fats, 


. 217 " 


Lactin, . 


. 341 " 


Salts, . 


. 43 " 



Total, . . 863 " = very nearly 2 oz. avoirdupois of water-free food. 

According to this, therefore, the infant at birth requires little more 
than -J pint imperial of unskimmed cow's milk ; the child at five or six 
months about 1^ pints imperial. 

It is evident that the proportion of fat and water is in great excess in, 
this exclusively milk diet ; but these two principles are required in early 
infancy in much larger relative amount than at a later period of life. It 
will also be seen that by diluting the above amounts of cow's milk with 
one to two parts of water, we obtain, as the proper amount of food for 
new-born infants, from a pint to a pint and a half; and for children about 
five or six months old, from 3 to 4 pints ; amounts which correspond closely 
with the results obtained from examination of the quantity of milk se- 
creted by nursing women. 

Some authorities recommend the regular use of lime-water instead of 
simple water, for the purposes of dilution. We ourselves have not been 
in the habit of using it, except when the rejection of the milk in hard 



30-4 THRUSH. 

and large curds, or the frequent appearance in the stools of small whitish 
lumps of undigested caseine, showed a too early and too great coagula- 
tion of the milk in the stomach. In such cases we always direct lime- 
water to be added to each meal. As to the quantity of this alkali, we 
will state that Dr. Eustace Smith (Wasting Diseases of Children, Lon- 
don, 1868, p. 33), directs, during the first six weeks of life, that half lime- 
water and half milk be used. Dr. Routh (Infant Feeding, 2d eel., London, 
p. 39 T) advises that from an ounce to an ounce and a half of lime-water 
be added to each pint of food. The latter is about the proportion we use. 
In man3 r cases, however, our patients do pei'fectly well without any. 

Besides the dilution with water, sugar must always be added. Form- 
erly, the best lump white sugar was always used. Brown sugar has been 
found not to answer well. Of late, experience has shown that sugar of 
milk, which is the natural sugar found in this fluid, has been found prefer- 
able to cane sugar. The amount of sugar of milk to be added should 
always be specified by the physician, and not left to the hap-hazard judg- 
ment of the nurse or mother, as most persons use too much. A drachm 
and a half, or about a heaped teaspoonful, is the proper proportion for 
each eight ounces of food. 

Many different and more or less complicated preparations of food have 
been recommended by different authorities. We do not think that d.uj of 
the various feculent substances, so much vaunted and advertised for the 
use of the public, are of any value in the early months, as compared with 
milk. Milk must be the basis. It is the realty important part of the 
nutriment. It matters not greatly what be the feculent substance used, 
we think, if only the milk be good and in sufficient quantity, and the 
feculent material be in small proportion. To depend on amylaceous food 
is usuall} T to sicken, and finally to starve the child. And }*et we have 
found b} T experience that a small quantity of amylaceous material com- 
bined with the milk does render the food more digestible. TVe think 
that the opinion held by several physicians, that the particles of starch 
lessen the tendency of cow's milk to coagulate into hard large masses, bj- 
being interposed between the elements of the caseine, may be the correct 
one. At all events, experience, as stated above, has led us into the habit of 
using a small quantity. The following preparation was published in our 
first edition, twent} T -one } T ears ago: and we have employed it in a great 
man}- instances, and have found it the best substitute, as a rule, for the 
natural aliment, that we are acquainted with. 

It is made by dissolving a small quantity of prepared gelatine or Prus- 
sian isinglass in water, to which is added milk, cream, and a little arrow- 
root, or any other farinaceous substance that ma}' be preferred. The 
mode of preparation and the proportions are as follows : A scruple of 
gelatine (or a piece two inches square of the flat cake in which it is sold) 
is soaked for a short time in cold water, and then boiled in half a pint of 
water until it dissolves, — about ten or fifteen minutes. To this is added, 
with constant stirring, and just at the termination of the boiling, the milk 
and arrowroot, the latter being previous^ mixed into a paste with a little 
cold water. After the addition of the milk and arrowroot, and just be- 



QUANTITY OF FOOD NEEDED BY CHILDREN. 305 

fore the removal from the fire, the cream is poured in, and a moderate 
quantity of loaf sugar added. The proportions of milk, cream, and arrow- 
root must depend on the age and digestive power of the child. For a 
healthy infant within the month, we usually direct from three to four 
ounces of milk, half an ounce to an ounce of cream, and a teaspoonful 
of arrowroot to a half pint of water. For older children, the quantity 
of milk and cream should be gradually increased to a half or two-thirds 
milk, and from one to two ounces of cream. We seldom increase the 
quantity of gelatine or arrowroot. 

"We have given this food to a great many children during the last 
twenty years, as well to those brought up entirety by hand, as those 
parti}' suckled, or weaned, and can truly state that they have thriven 
better upon it than upon anything else we have employed. In several 
cases it has agreed perfectly well with infants who could not, without 
vomiting, diarrhoea, and colic, take plain milk and water, cream and 
water, an}' kind of farinaceous food prepared with water, chicken water, 
or in fact any other food that had been tried. In the cases of sick chil- 
dren, it ought sometimes to be made even weaker for a while than in the 
proportions first mentioned above. 

We have been pleased to find that Dr. Routh (loc. cit., p. 315) quotes, 
with great approval, a food recommended by Dr. Merei for feeble chil- 
dren, with bowels previously deranged, which is almost exactly the same 
as the above. Dr. Merei is one of the physicians of the Clinical Hospital 
for the Diseases of Children, in Manchester, and one who must, therefore, 
have had a large experience. He first makes a decoction of arrowroot 
with a teaspoonful of arrowroot to three-quarters of a pint of water, this 
quantity to serve for a whole day's supply. It is stated by Dr. Routh, 
that the arrowroot is not given as an aliment, but as a softish substance, 
to soothe mechanically the irritation of the intestinal mucous membrane. 
"Langenbeck, indeed," he says, "believes that in such cases the granules 
of starch intersperse themselves between the particles of casein, and thus 
in great measure prevent the formation of hard, indigestible curds." The 
mixture Dr. Merei gives, is stated to consist of three or four parts of this 
thin decoction of arrowroot, to one part of new milk, slightly boiled ; and 
to the twenty-four hour's amount of food thus prepared, he adds about 
one or two tablespoonfuls of cream. Children, it is further stated, will 
digest well from a pint to a pint and a half of this mixture in twenty-four 
hours, according to their age. As they grow older, he increases the pro- 
portion of milk, but not of cream. 

This is so much like our own preparation, recommended twenty-one 
years ago, that we feel strengthened in our own conviction as to its util- 
ity, particularly as the two experiences have occurred so far apart as 
England and America, and to persons who have reached the result by 
experience as well as theory. 

There are other preparations, such as those of Dr. Franklancl and Mr. 
Lobb, which may do well in some cases, but they are so complex, and 
require so much time, as to render them almost useless in the nursery. 
The one recommended by Baron Liebig, called Liebig's food, we have 

20 



306 THRUSH. 

used occasionally, but have been disappointed in its action ; and it, like- 
wise, is so difficult of preparation, that we doubt its coming into general 
use in the nursery, where a food, to be well and properly prepared, must 
be simple. 

The causes which compel us to resort to artificial food for young chil- 
dren, are, of course, very numerous. Thus, it may be impossible, after 
the death of the mother, to secure a reliable wet-nurse ; or the mother's 
supply of milk may be manifestly insufficient ; or, again, although the 
quanta is abundant, the milk either disagrees with the child, and causes 
vomiting and diarrhoea, or does not nourish it properly. In every case, 
therefore, where we have reason to suspect that the mother's milk is of 
improper quality, we should subject it to a careful examination; and, it is 
needless to add, that whenever a wet-nurse is chosen, a similar examina- 
tion of her milk should invariably be made. 

According to Yernois and Becquerel, who examined the milk of eighty- 
one nursing women, the composition of a healthy woman's milk is as 
follows : 

1000 parts of milk contain — 

Water, 889.08 

Sugar, 43.64 

Caseine, 39.24 

Butter, 26.66 

Salts, 1.38 

For practical purposes, however, it is quite sufficient for the plrysician 
to determine the specific gravity, the reaction, the amount of cream, and 
the microscopic appearances of the milk. The first three of these points 
are to be ascertained in the way already directed in the examination of 
cow's milk. The density of the milk should be about 1030 to 1032. 
The amount of cream, as tested by the graduated galactometer, should 
be at least three per cent. In regard to the reaction, our own observa- 
tions are not in accordance with the statements of the majorhty of authors. 
Thus, according to Yogel (op. cit., p. 32), a "fresh woman's milk is bluish- 
white or pure white, has a feebly sweetish taste, and alkaline reaction.'' 1 
In order to determine this point, the following observations were made 
on forty-three women in the Philadelphia Hospital : 

The subjects chosen were all in good health, and varied in age from 
nineteen to forty-one years. They were all suckling their own children, 
who were from nine weeks to eighteen months old, and, in three-fourths 
of the instances, in good health and well grown. In a good many cases 
the children had suffered more or less severely from diarrhoea during 
their teething. 

The mode of testing was as follows : A few drachms of milk were first 
expressed from the nipple and rejected ; a couple of drachms more were 
then expressed into a spoon, and tested with litmus and turmeric papers. 
In no instance was there the slightest alkaline reaction with the turmeric. 
In one instance onlj r was there an acid reaction, and that a veiy faint 



MICROSCOPIC EXAMINATION OF MILK. 307 

one ; while in forty-two of the forty-three cases, in nineteen of which the 
milk was tested twice, on successive clays, the reaction was neutral. 

It is necessary, in thus testing the milk, to express it into a spoon, 
since litmus paper is reddened when applied to the moist nipple. 

It would appear, then, from these observations, that woman's milk can, 
at least, not be regarded as unhealthy on account of having a neutral 
reaction. 

The microscopic examination should determine the quantity and size 
of the fat-globules, and the presence or absence of colostrum corpuscles. 

The fat-globules, also called milk-globules, which are observed in healthy 
woman's milk, should not be very numerous, and should not vary in size 
more than from the 0.0012 to 0.0020 of an inch in diameter. The fat- 
globules, as present in milk, are invested with a delicate albuminous en- 
velope. If the milk be allowed to stand, and the upper stratum of cream 
which forms be examined, along with the ordinary fat-globules, there will 
be numerous others of much larger size. 

In addition to these fat-globules, there are also found in the milk during 
the first two or three weeks after confinement, a number of granule-cells, 
the so-called "colostrum corpuscles." These bodies, which present the 
ordinary appearances of granule-cells wherever found, consist of an 
aggregation of minute oil-globules in an albuminous basis ; they vary 
from 0.003 to 0.006 of an inch in diameter ; and when examined by trans- 
mitted light, appear opaque and dark-colored. After the period above 
mentioned (end of the second week), they should diminish rapidly in 
number, and only reappear in case the nursing woman is attacked with 
any acute febrile affection. If, therefore, they are found to persist long 
after the time mentioned, or if, having almost disappeared, they return 
in numbers, the milk must be regarded as unhealthy. 

After these general remarks on the diet for hand-fed children, which 
we hope will not be thought too tedious, having regard to the great im- 
portance of this subject, not only in thrush, but in all the diseases of child- 
hood, we return to the treatment of the special disease under considera- 
tion, thrush. 

Few children, with thrush, unless the case be a very mild one, will take 
the full allowance of milk and water we have assumed to be necessary in 
the first weeks after birth. It is clear, however, that if the patient be 
taking only half a pint or a gill a day, it cannot live long on so much less 
than the natural quantity. It ought to take, under these circumstances, 
about two or three tablespoonfuls of food every two or three hours, be- 
tween morning and evening, and once or twice in the night, which would 
amount to from eight to ten ounces in the day ; and this quantity ought 
to be given if the child can be induced, without forcing, to take so much. 
If the usual proportion of two parts water to one of milk, or if the 
arrowroot and gelatine preparation above recommended, should be re- 
jected in hard curds, or if masses of undigested curd be found in the 
stools, it is best, for a few days, to dilute with three or even four parts of 
the arrowroot solution, or to try for a short time, merely cream and water, 



308 THRUSH. 

one part of the former to three, four, or five, of the latter, returning to 
the mixture of cream, milk, and water, as soon as possible. 

In mild cases of the disease, which have been caused by some tempo- 
rarily unhealthy state of the nurse's milk, or, as we have seen it, from 
the occasional use of artificial food to eke out a diminished supply on the 
part of the nurse ; after regulating the diet as directed, the use of the 
following mixture, which we have employed for many years past, will 
often prove very successful and tranquillizing : 

R. — Soda? Bicarb., gss. 

Tr. Opii Camph., gtt. xl. 

Tr. Khei, gtt. Ixxx. 

Syrup. Simp., f^ij. 

Aq. Menth, f^xiv.— M. 

A tea.spoonful three times a day. 

This dose, continued for several days, or even weeks, will, unless the 
cause continue in force, relieve the pain and wakefulness, lessen the diar- 
rhoea, and greatly promote the comfort of the child. In connection with 
this, the mouth should be touched, once or twice a day, with a solution 
of nitrate of silver, of one grain to the ounce. 

In the grave form of the disease it is necessary, after regulating the 
diet, to employ remedies for the disordered condition of the alimentary 
canal. These should consist principally of alkalies, astringents, opiates, 
occasionally a dose of some laxative substance, nitrate of silver, and the 
external employment of baths, warm cataplasms to the abdomen, and 
sometimes of revulsives. 

The alkalies usually employed are soda, lime-water, magnesia, chalk, 
and prepared crab's-ej^s. Of these we prefer, in most cases, the soda, 
lime-water, chalk, or crab's-eyes, to be given in the manner which will be 
recommended in the article on entero-colitis. Dewees recommends very 
highly the following formula : 

R. — Magnes. Alb. Ust., ..... gr. xij. 

Tinct Thebaic, gtt. iij. 

Sacch. Alb., . . . . . . q. s. 

Aquae Font., f£j.— M. 

A teaspoonful to be given every two hours until the bowels are tranquil. 

He saj^s of it that he has "long adopted it with entire success." In con- 
junction with the internal use of alkalies and astringents, we would rec- 
ommend the practice pursued by M. Yalleix of emploj'ing opiate enemata 
and warm poultices containing laudanum, applied upon the abdomen. 
The enemata should consist of one drop of laudanum in a tablespoonful 
of starch-water for 3 r oung infants, to be used morning and evening. The 
poultices ma} r be made of Indian or flaxseed meal, placed between two 
pieces of soft gauze flannel, to be secured around the body by a band, 
and renewed from time to time. 

Purgative remedies are much used in this country in all cases of intes- 
tinal disorder. We believe them to be unnecessary, and generally inju- 



LOCAL TREATMENT. 309 

rious. in thrush, except at the onset, and occasionally through the course 
of the disease, when we may suppose the bowels to contain accumula- 
tions of partially digested aliment, or highly irritating secretious. Under 
these circumstances, and only then, from half a teaspoonfnl to a teaspoon- 
ful of castor oil, or a teaspoonfnl of spiced syrup of rhubarb, containing 
half a drop of laudanum, ma}' be prescribed, and repeated in case the 
same condition of things should recur. When once the diarrhoea with 
green watery stools is established, we believe all cathartics to be, as a 
rule, injurious. 

Opiates, in moderate quantities, given in combination with alkalies or 
astringents, or used b} T injection or externally, are of the greatest service 
at all stages of the grave form of the disease. When the diarrhoea is 
severe and obstinate, and particularly when the stools contain mucus or 
blood, or are attended with tenesmic straining, nitrate of silver given in- 
ternally, and used by injection, may be resorted to with very probable 
benefit. The doses and modes of administration will be described under 
the heads of entero-colitis and ctysentery. 

Some authors recommend the application of one or two leeches to the 
margin of the anus, or over the left iliac fossa. We think they can rarely 
be proper, and if so, onlv in vigorous, hearty children, and in cases pre- 
senting strongly marked inflammatory symptoms. When the symptoms 
indicate great exhaustion, or tend towards a state of collapse, resort must 
be had to stimulants, of which the best are weak brandy and water, or a 
mixture of equal parts of wine-whey and arrowroot water. 

Local Treatment. — The local treatment is important in all cases, but 
is of much less consequence than the general treatment, and particularly 
attention to the diet and other hygienic conditions of the patient. 
Topical remedies undoubtedly have the effect, however, in some in- 
stances, of arresting the progress of the exudation, and hastening the 
resolution of the disease of the mouth ; but we have uniformly found, in 
grave cases, that no remedies applied to the mouth had any decided influ- 
ence upon the abdominal disease, which is, after all, the cause of the fatal 
termination in the vast majority of cases. The local treatment ought, 
therefore, to be regarded as adjuvant only to the general management of 
the disorder. 

In mild cases the most suitable local treatment, the one recommended 
by Underwood, Dewees, Eberle, and MM. Trousseau and Delpech, and 
that which we have generally employed, is the occasional application to 
the mouth of borax. It m&y be used mixed with an equal quantity of 
honey, and applied by means of a rag or pencil ; or with an equal quan- 
tity or two parts of finely-powdered white sugar, of which a pinch is to 
be put upon the tongue every two or three hours ; or in solution, in the 
proportion of a drachm to two ounces of water. The best mode probably 
is to mix it with honey. If this application fail to arrest the deposit of 
the exudation, we may resort to alum in powder or solution, or, better 
still, to solutions of nitrate of silver, or to careful cauterization with the 
solid nitrate. The alum may be used in the same manner as borax, or 
according to the following formula, recommended by M. Yalleix : 



310 SIMPLE PHARYNGITIS. 

Be. — Aluminis, gr. xv. 

Mel Rosae. ...... gijss. 

Decoct. Hordei, ..... f^iijss. — M. 

In the use of the nitrate of silver, we should resort to a solution of five 
grains to the ounce of water. MM. Trousseau and Delpech, however, 
eniplo}^ one of thirt}- grains to the half ounce, or more frequently cauterize 
lightly the whole mucous surface with the solid caustic. 

Between the application of any of the above-mentioned remedies, the 
mouth of the infant ought to be occasionally moistened and cleansed with 
some of the mucilaginous solutions, as gum-water, flaxseed tea, or that 
made from sassafras pith, slippery elm bark, or marsh-mallow root. 

Strict and careful attention must be constantly paid to the state of the 
skin around the anus, and upon the thighs and buttocks. These parts 
ought to be well cleansed, after each evacuation of urine or stool, by 
gentle pressure, and not b}^ rubbing, with a fine sponge dipped into tepid 
milk and water, then dried with a soft napkin in the same manner, and 
well anointed with simple cerate, or, what we find better than anj'thing 
else, Goulard's cerate. These precautions ought to be still more carefully 
observed if erythema has already made its appearance. 



ARTICLE VI. 

SIMPLE OR ERYTHEMATOUS PHARYNGITIS. 

Definition ; Synonymes ; Frequency. — Simple pharyngitis consists 
of an erythematous inflammation of the pharynx, tonsils, and soft palate, 
unaccompanied by ulceration, deposit of false membrane, or gangrene. 
It is not mentioned by Underwood. It is described under the title of 
C3manche tonsillaris by Dewees and Eberle, and of tonsillitis by Stewart 
and Condie. It is very frequent both as an idiopathic and secondary dis- 
ease. We constantly meet with it in children of all ages during the cool 
months of the 3-ear. 

Causes. — It may occur at all ages, and is equally common in the two 
sexes. It is more frequently a seconclar}' than an idiopathic affection. 
The diseases in the course of which it is most apt to occur are scarlet 
fever and measles, and next pneumonia and bronchitis. It is often an 
accompaniment of simple laryngitis. The idiopathic form is most com- 
mon in this city in the late winter and early spring months. It is said to 
prevail sometimes in an epidemic form. 

The exciting causes of the disease are not always easily detected. In 
most instances, however, we believe that exposure to cold is the cause of 
the attack. 

Anatomical Lesions. — In mild cases the alterations of texture ob- 
served during life, and in a few instances after death, the patient having 



SYMPTOMS. 311 

died of some other disease, consist of greater or less redness, swelling, 
softening, and a rough or granular and sometimes oadematous condition 
of the mucous membrane covering the soft palate, tonsils, and pharynx. 
The uvula and tonsils are generally tumefied, and the crypts of the latter 
filled with mucous or purulent fluid of a yellowish color. In one very 
severe case which proved fatal, MM. Rilliet and Barthez found the tonsils 
very red, soft, only slightly swelled, and infiltrated with pus ; the pharynx 
was covered with a thick layer of bloody mucus ; the mucous membrane 
of the throat was of a dark red color, thickened, and granular, but not 
softened. The submaxillary glands were of a grayish color, enlarged 
and soft. 

Symptoms. — Simple pharyngitis of moderate severity begins with rest- 
lessness, irritability, fever, slight cough, and in some instances, pain in 
the throat, which is complained of by older children, and betrayed in 
those who are very young, by the refusal to nurse or take food, because 
of the difficulty of swallowing. The face is generally flushed, sometimes 
very deeply so. Young children are often drowsy, but from irritability 
and fever refuse to sleep except on the lap. The fever is marked by 
acceleration of the pulse, which rises to 100, 110, or more in children 
over five years of age, and to 120, 130, or 140 in those under that age, 
and by unusual warmth or even heat of the skin. At the same time the 
respiration is generally more frequent than natural, but almost always 
regular ; in cases attended with high fever, we have counted the breath- 
ing at 42 and 50. Auscultation reveals pure vesicular murmur or slight 
sibilant rhonchus. The voice is clear, or, in rather severer cases, obscured 
and nasal, and in some instances, speaking is painful and difficult. Cough 
is a frequent symptom. It was present in 20 of 25 cases observed by 
ourselves. In 6 of these it was harsh and croupal, so that the children 
seemed threatened with croup. The croupal sound seldom lasted over 
one night, after which the cough was merely hoarse, and gradually be- 
came loose towards the termination of the attack. In the remaining 
cases it was rare and dry in the beginning, and more frequent and looser 
as the disease progressed. Pain is a frequent, but far from constant 
S3 T mptom at the outset of the disease. It generally exists during deglu- 
tition. When present it is shown in infants, as stated, by their refusing 
the breast, or nursing only at long intervals, and with difficulty ; while in 
older children it is complained of. It is not, however, a constant symp- 
tom, as we have often seen children of one, two, and three years old, with 
severe angina productive of violent fever, who swallowed fluids and soft 
solids without a sign of pain. Of 22 cases in which the state of this 
symptom was particularly noticed b}^ ourselves, it was present only in 7. 
Throughout the acute period of the disease there is generally considera- 
ble thirst; the appetite is diminished or entirely suppressed; the stools 
are usually natural, or there is slight constipation. 

The throat should always be examined when there is the least reason 
to suspect that an attack of sickness depends upon inflammation of that 
part, and whenever a child has been seized suddenly with fever, particu- 
larly in cold weather, and there is nothing more evident by which to ex- 



312 SIMPLE PHARYNGITIS. 

plain the illness. To examine this part well, the tongue must be strongly 
depressed with the handle of a spoon, which should be carried back to 
the base of the tongue. This may be done in the youngest infant. 

The appearances presented by the throat are as follows : The soft 
palate, uvula, tonsils, and generally the pharynx also, are more or less 
reddened and swelled, and the mucous membrane commonly looks rough 
and granular. The fauces are often filled with frothy mucus, and in se- 
vere cases, coated all over with mucous or purulent secretions, which 
sometimes line the inflamed surfaces in such a way as to resemble false 
membranes. They are to be distinguished only by careful examination, 
and b}^ removing a small portion on a pencil or sponge mop, in order to 
ascertain their real nature. We have seen the mild form of inflammation 
in a child ten days old, in one eight weeks, another three months, and a 
fourth nine months old. 

Dr. Wertheimer {Jour, fur Kinderkrankheiten, Band xxxii), calls at- 
tention to a variety of angina, which he calls oedematous, and which is 
specially characterized by serous infiltration of the submucous tissue of 
the pharynx, the mucous membrane itself being pale and smooth, and 
soft and sticky to the touch. 

The submaxillary glands and neighboring cellular tissue are sometimes 
swollen, in consequence of the extension of the inflammation to them. 
This is often evident to the eye, but it is more correctly judged of by the 
touch. At the same time the glands are usually somewhat painful to the 
touch. The amount of swelling is slight in very mild cases, or there may 
be none at all. In severer cases it is much more considerable. 

The breath is said to be often fetid. We have not met with this char- 
acter in the simple disease. Expectoration is rarely present. We have 
never noticed it under six 3'ears or age. Slight nervous symptoms occur 
in nearly all the cases, consisting, as already stated, of restlessness and 
irritability in mild attacks, and of insomnia or drowsines, with starting 
and twitching, in those which are more severe. 

The fever generally occurs at first only in the after-part of the day and 
during the night, often becoming intense at that time, with restlessness 
and starting, and subsiding or disappearing entirely towards morning, to 
recur again the next afternoon or evening. Children not unfrequently 
pla} T about all the early part of the day, and are attacked with the S} T mp- 
toms just mentioned as night comes on. The disease generally pursues 
this course for three or four days, and then passes awaj^ entirety or, if it 
lasts beyond that time, the fever becomes continued, and the attack runs 
on for seven, eight, or ten days. 

In grave cases of simple angina, the disease begins with vomiting, fever, 
and severe nervous symptoms, in the shape of excessive restlessness, or 
somnolence, and occasionally convulsions. The fever is violent, the pulse 
being very frequent and full, and the skin hot and flushed. The intense 
heat and flushing of the skin, which in sanguine children sometimes 
affects the greater part of the surface of the body, together with the 
activity of the circulation, not unfrequently make the onset of the dis- 
ease resemble very closely that of scarlet fever. Four cases of this kind 



SYMPTOMS — DIAGNOSIS. 313 

that have come under our notice presented severe nervous symptoms at 
the invasion. In a girl between two and three years old, they consisted 
of wildness and ecstatic expression of the face, and trembling uncertain 
movements of the limbs, which would probably have terminated in convul- 
sions, but for the timely interposition of a warm bath. In the three others, 
general convulsions occurred. Two of the subjects in which convulsions 
took place were between five and six years old, and one between three 
and four. In two the convulsions occurred at the onset, and in a third 
on the second day. The convulsive movements lasted from ten to twenty 
minutes, and were followed by somnolence for a few hours in two, and by 
stupor for a day in the third. It should be stated, however, that two of 
these subjects were predisposed by constitution and temperament to 
spasmodic attacks, as one had had a fit previously from a similar cause, 
and the other two from difficult dentition. The third had never suffered 
from any symptoms of the kind, and did not appear predisposed to them. 

The tongue is generallj' dry and coated with a thick whitish fur in grave 
cases; the respiration is quick, loud, and nasal; and the voice guttural or 
nasal, and difficult. There is usually extreme thirst, and not unfrequently 
delirium. The throat is commonly violently inflamed, of a deep red color, 
and coated over with mucous or purulent secretions. The submaxillary 
regions are often swelled, and the deglutition sometimes, though not 
alwa} T s, difficult. "When the disease proves fatal, the different symptoms 
soon reach their height, and death may occur in two or three days. We 
have never, however, known simple pharyngitis to terminate fatally. 
The duration of the grave cases is variable. In the four that we have 
noted, it was between three and eight days. 

Secondary pharyngitis, which, as has been stated, is a very frequent 
disease, will be treated of in the articles on the various diseases in the 
course of which it occurs. 

Diagnosis. — The diagnosis of simple pharyngitis is not always without 
difficulty, as there are no local symptoms in two-thirds of the cases at the 
invasion, nor in some instances' at any period of the attack. The phy- 
sician and attendants, therefore, are often deceived as to the real cause 
of the violent fever which has so suddenly made its appearance, and are 
disposed to refer it to any but the true one. 

It has happened to us several times in cases of children attacked with 
simple angina, to suspect pneumonia from the sudden occurrence of fever, 
rapid respiration, slight dry cough, and the absence of pain in the throat, 
difficulty of deglutition, or other symptoms, to call our attention to the 
real seat of disease. The diagnosis is to be corrected only by the absence 
of the physical signs of pneumonia, and the consequent necessity of find- 
ing some other cause of the sickness. Angina may be mistaken also for 
indigestion, which is one of the most frequent causes of sudden fever in 
childhood, and is accompanied, like severe angina, b} r vomiting. The 
distinction between the two is to be made by careful inquiry as to the 
history of the attack, by examination of the matters ejected from the 
stomach, and by inspection of the throat. Severe cases, particularly 
when ushered in by convulsions, may be mistaken for disorder of the 



314 SIMPLE PHARYNGITIS. 

nervous system dependent upon dentition. The only method of ascer- 
taining the truth is again the inspection of the throat. Cases of this 
kind might also be mistaken for the beginning of scarlet fever. Time 
only, and the development or absence of the symptoms peculiar to the 
latter disease, could enable us to determine the diagnosis. 

The diagnosis between simple and pseudo-membranous pharyngitis will 
be given under the head of diphtheria. 

Prognosis.. — Simple pharyngitis of moderate severity is very rarely, if 
ever, a fatal disease. Severe or grave erythematous pharyngitis, on the 
contrary, is often a dangerous malady. The four cases that have come 
under our care, however, all recovered. The unfavorable symptoms in 
such cases are : very violent fever, greatly altered phj^siognom} 7 , difficult 
respiration, choked and guttural voice, excessive jactitation, delirium, 
convulsions, and coma. 

Treatment. — Mild cases of simple angina need but little treatment. 
The child ought to be confined to a warm room in all cases, and kept in 
bed, or on the lap, if it have fever. The diet must be restricted to milk 
preparations and bread, so long as the fever continues. The therapeutical 
part of the treatment may consist in the use of some mild evacuant, as 
one or two teaspoonfuls of castor oil, half a teaspoonful or a teaspoonful 
of magnesia, a small quantity of syrup of rhubarb, or what is all-sufficient 
in many cases, a simple enema. At the same time we may give, if the 
frequency of pulse, heat of skin, and restlessness be considerable, a few 
doses of spirit of nitrous ether, or spiritus Mindereri, alone, or combined 
with from one to four drops of antimonial wine, according to the age. 
A warm bath, if the child is not afraid of it, is an admirable remedy 
when there is much excitement of the circulation; or a foot-bath, con- 
taining salt or mustard, may be used. Frictions over the throat and neck 
are often very advantageous ; they maj^ be made with hartshorn and sweet 
oil, with or without the addition of laudanum, or a small quantity of spirit 
of turpentine maybe applied upon the skin, so as to produce slight coun- 
ter-irritation. When there is much pain and difficult} 1 ' of deglutition, the 
case is best treated by the use of nitrate of silver in solution (5 or 10 
grains to the ounce), or of powdered alum, applied by means of a large 
throat-brush. 

In the severe form of the disease the treatment must be much more 
active than in mild cases. When the fever is very high, and threatening 
nervous S3 T mptoms are present, the most speedy means of controlling 
them is a warm bath, continued for fifteen or twenty minutes. If the 
effects of this should be slight or transitory, one or two leeches may be 
applied behind the angles of the jaw, unless the fright and consequent 
resistance on the part of the child are so great as to render their applica- 
tion objectionable. Some evacuant dose should be given early in the 
attack; it ma}^ consist of castor oil, magnesia, epsom salts dissolved in 
lemonade, fluid extract of senna, or infusion of senna and manna. The 
quanthVy must be sufficient to produce several copious stools, and should 
it fail to operate in three or four hours, and the fever continue, it is al- 
wa}*s well to assist it by means of a purgative enema. Two hours after 



DISEASES OF THE STOMACH AND INTESTINES. 315 

the exhibition of the cathartic, it will be proper to resort to small doses 
of antimonial wine, with nitre, repeated every hour and a half or two 
hours, in the manner recommended in the article on pneumonia. If the 
secretious into the fauces be very abundant and tenacious, so as to im- 
pede respiration, the best means of getting rid of them is by an emetic of 
ipecacuanha, hive syrup, or antimonial wine. If thej^ collect again, the 
throat ought to be cleansed from time to time with a small sponge-mop. 
The inflamed surfaces should be touched two or three times a day with 
a solution of nitrate of silver (from five to ten grains to the ounce). The 
late Dr. C. D. Meigs was in the habit of employing with much benefit, in 
the severe angina of children, whether idiopathic or secondary, a wash 
made according to the following formula : 

R. — Cupri Sulphat., 

Quinias Sulphat., aa, gr. vj. 

Aquae Destillatae, f^j. — M. 

This is applied in the same way as the lunar caustic solution, and we 
have frequently seen it produce most excellent effects. 

The four grave cases observed by ourselves recovered under very 
simple treatment. This consisted in the use of the warm bath, of doses 
of castor oil to move the bowels freely on the first day, and of syrup of 
rhubarb or enemata afterwards to keep them soluble ; of doses of anti- 
monial wine and nitre every two hours in such quantity as to avoid sick- 
ness ; of mustard foot-baths ; stimulating frictions to the outside of the 
throat; applications of lunar caustic solution to the throat internally, 
three or four times a day ; and of rigid diet. In one case the warm bath 
was used three times in a single day, because of the extreme restlessness 
and heat of the skin, and was productive each time of much benefit. 



CHAPTER II. 

DISEASES OF THE STOMACH AND INTESTINES. 

GEXERAL REMARKS. 

In our division of these diseases, we shall treat first of Indigestion, 
using this term to signify morbid conditions of the digestive function, 
which we suppose to be the result of functional disorder, or of mild, 
acute or chronic catarrh of the stomach. Under the title of Gastritis 
we shall describe the much more rare and dangerous form of disease, in 
which there is acute inflammation of one or more of the coats of the 
stomach, and which is seldom met with except as the consequence of the 
application of some direct irritant to the organ. 

We shall then describe Simple Diarrhoea, in which we suppose the in- 



316 INDIGESTION. 

testinal disorder to be either merely functional, or one of slight catarrhal 
inflammation of the mucous membrane. Xext, under the title of Entero-co- 
litis or Inflammatory Diarrhoea, we shall treat of that form of diarrhoea 
which is now by many writers styled acute or chronic catarrh of the in- 
testinal mucous membrane, and the chronic forms of which we believe to 
be of the same nature as the disease designated by most of the observers 
whose experience was gathered in the vast field of the late war, chronic 
diarrhoea. TVe shall pass on then to Cholera Infantum, limiting this term 
to cases in which the disease is of a true choleraic type; and, lastly, we 
shall consider Dysentery. TVe have also added separate articles on the 
diseases of the Ccecum and Appendix Yermiformis, and upon Intussus- 
ception. 



SECTIOX I. 
FUNCTIONAL DISEASES or mild catarrh of the stomach and intestines. 

ARTICLE I. 

IXDIOESTIOX. 

Deeinition; Frequency; Forms. — By the term indigestion, we mean 
that condition of the stomach in which its function of digestion is dis- 
turbed or suspended, independent of inflammation or other disease of the 
organ, appreciable by our senses; or in which there has been found after 
death, in the few opportunities that have been met with to make such an 
investigation, the lesions which are now usually designated as mild gas- 
tric catarrh. The only anatomical alterations found in such cases, are 
reddening of the mucous membrane in spots by a fine injection, relaxa- 
tion of its tissue, and the presence of a layer of tough mucus. It is a 
very frequent affection during the whole period of childhood, and is one 
of great importance on this account, and from the fact of its laying the 
constitution open, by the debility and cachexia which it produces, to va- 
rious secondary affections. In our description of the disease, we shall 
distinguish between the forms which occur during infancy, and after the 
completion of the first dentition. 

Causes. — The principal causes of indigestion in infants are an un- 
healthy state of the milk of the nurse, the use of artificial diet, and lastly, 
an impaired condition of the digestive function, which disables the stom- 
ach from digesting even the most healthful aliment. 

The milk of the nurse may be too old for the child, for it has been 
found that a breast several months old, sometimes, though not always, 
disagrees with a young infant, in consequence, no doubt, of the milk 
being thicker and richer at that time than immediately after parturition. 
The breast-glands may continue to secrete colostrum for weeks or even 
months after parturition, and when this is the case the child is almost 
sure to suffer frorn indigestion and diarrhoea. The milk may be unwhole- 



SYMPTOMS. 317 

some because the nurse is in bad health, or because her diet is not prop- 
erly regulated. That the diet of the nurse affects her milk, we have no 
doubt, though it has been deuied by some persons. 

We have known several children to suffer from indigestion, attended 
with vomiting, acid secretions, colic, and diarrhoea, in consequence of the 
nurse having indulged in a very rich diet, and particularly in vegetables 
and fruits. We do not mean to assert that all nursing-women should abstain 
from fruits, or even live on a very simple diet, for we have known some 
who could make use of the richest food, and eat abundantly of all kinds 
of vegetables and fruits, without the least injury to the child. But there 
are others who cannot do so without occasioning indigestion in their in- 
fants, because, probably, their children are unusually susceptible to the 
action of the materials absorbed from that kind of food. Again, it is 
clearly proved by recorded cases and by the opinions of various authori- 
ties, that the milk of the nurse is affected by her moral condition. Chil- 
dren have been known to suffer greatly, and even to die, from taking the 
milk of a nurse who had just before undergone a fit of violent anger. The 
depressing moral emotions, as anxiety, grief, fear, and despair, are well 
known to affect the milk secretion in such a way as sometimes to occasion 
indigestion. 

The use of artificial diet for young infants, or as the expression is, 
"bringing up on hand or the bottle," is, we believe, by far the most fre- 
quent cause of indigestion during infancy. Very many children with whom 
this is attempted, die of indigestions, chronic diarrhoeas, gastritis, entero- 
colitis, cholera infantum, and thrush. Yery few escape frequent attacks 
of one or other of the diseases just named. Much depends, no doubt, on 
the selection and preparation of the food. It may be stated as a well- 
established fact, that a diet consisting wholly or in a great part of fari- 
naceous substances, very rarely fails to disagree with the child, and to 
produce indigestion and other disorders of the digestive system, which 
often prove fatal; while one in which cow's or goat's milk enters as the 
principal ingredient, though inferior to the natural aliment, and often pro- 
ductive of indigestion, is far less injurious than the one before spoken of. 

A third cause of indigestion was stated to be the absence or loss of the 
digestive power of the stomach, independent of the nature of the food. 
This is a condition similar to the dyspepsia of the adult. It may be con- 
genital or may result from causes brought into action after birth. It often 
remains as a consequence of previous indigestions from improper or ex- 
cessive feeding. It exists during the invasion, course, and convalescence 
of various diseases. Dentition frequently diminishes or impairs the tone 
of the digestive function, so that the child is often unable, during that 
process, to digest aliment which had agreed with it perfectly well at other 
times. 

The causes of indigestion after the completion of the first dentition are 
congenital feebleness of the digestive function ; a certain want of power 
of that function, which remains often for years in children reared upon 
artificial diet, and in those who have been debilitated by frequent attacks 
of disease of any kind ; the habitual use of improper diet ; the eating of 



318 INDIGESTION. 

crude, indigestible food ; the process of the second dentition ; the want 
of due exercise in the open air ; residence in large cities ; and undue ex- 
ercise of the mental faculties in the conduct of the education of the child. 

Symptoms. — We shall describe first the symptoms of indigestion as it 
occurs during infancy, and secondly as it occurs during childhood, or 
after the completion of the first dentition. 

Indigestion during infancy may be advantageously considered under 
two heads : as occasional or accidental, and as habitual. B} T the former 
we mean that which occurs in a health} T infant from a transient cause, 
such as repletion or a momentarily unhealthy state of the nurse's milk 
from some imprudence on her part as to diet, from some moral cause, or 
from sickness ; and that which depends upon the passing influence of 
dentition. B}^ habitual indigestion, we mean the form of the affection 
which is long continued in consequence of a persistence of the cause. 

The symptoms of occasional or accidental indigestion in infants are: 
paleness and contraction of the face ; restlessness and peevishness ; moan- 
ing and ciying, or in some cases, screaming ; nausea, shown by excessive 
paleness, often \)j very great languor, and by occasional retching, which 
may either subside without vomiting, or as more frequently happens, ter- 
minate in that act; flatulent distension and hardness of the abdomen, 
especially in the epigastric region, often accompanied with eructations; 
and in many of the cases simple diarrhoea. These symptoms usually come 
on soon after nursing freely, or after a very hearty meal of artificial food, 
in a child previously in good health. The attack seldom lasts more than 
a few hours or one or two days. The vomiting which almost always takes 
place, and which relieves the stomach from the offending cause, very often 
accomplishes the cure. 

Habitual indigestion in infants causes a train of symptoms which are 
different from, and much more severe than those just described. Of these 
the most important are : frequent attacks of nausea and vomiting, and of 
simple diarrhoea repeated for days, weeks, or months in succession; pale- 
ness, or some other unhealthy tint of the cutaneous surface; continual 
restlessness and discomfort, with fretting or crying, particularly in the 
after-part of the day and during the evening and night, in place of the 
natural ease and quiet of a healthy infant ; constant fits of the most vio- 
lent screaming from colic, sometimes lasting for hours ; dull and languid 
expression of the countenance, or else an uneasy, contracted look, like 
that produced by continued suffering ; more or less emaciation ; failure of 
the natural growth in stature and size, so that the child is small and puny 
for its age ; want of calorific power, causing the child to suffer unusually 
from cold, as shown hy frequent coolness of the hands and feet ; irregular 
appetite, which makes it necessary to tempt by frequent changes of the 
food, or more or less complete anorexia; and lastly, the various symptoms 
that indicate an impoverished state of the blood and bad nutrition. 
, In some cases there are added to the above symptoms, or there follow 
as a consequence of the indigestion, those of gastritis or entero-colitis,. to 
be hereafter described. Indigestion probably seldom proves fatal in in- 
fants, except from the occurrence of some inflammatory complication, as 



SYMPTOMS. 319 

for instance, one of the diseases just named, or acute disease of some 
other principal organ. 

Indigestion in children who have completed the first dentition may, as 
in the case of infants, be occasional or habitual. Occasional indigestion 
occurs in strong and vigorous, as well as in more delicate subjects. The 
attack generally begins, within a few hours or a daj T after the child has 
eaten some indigestible substance, with languor and chilliness in older 
children, and with languor and peevishness in those who are younger; 
after which there is headache, pain in the stomach in most of the cases, 
and very often a disposition to somnolence. If the child is attacked with 
vomiting soon after the appearance of these s3 T mptoms, and ejects the of- 
fending material, it will often seem perfectly well from that time. If, 
however, this do not take place, fever, sometimes of a violent character, 
is almost certain to make its appearance. The pulse becomes very fre- 
quent, rising to 120, 130, 160 or over, and being full and resisting; the 
skin becomes flushed, dry, and very hot ; the appearance of the tongue is 
not generally changed early in the attack ; there is considerable thirst ; 
the child is restless and uneasy, tossing from side to side, or it lies in an 
uneasy sleep, attended with frequent starting and jerking of the limbs or 
ciying out ; the abdomen is natural, or hard and distended over the epi- 
gastric region. When the symptoms just described make their appear- 
ance suddenly, by which we mean in the course of a few hours, in a child 
two, three, four or five 3-ears old, after it has eaten some indigestible sub- 
stance, there is reason to fear an attack of convulsions. The probability 
of the occurrence of this accident is great in proportion to the earliness 
of the child's age, and the impressibility of its nervous system. The 
attack is particularly to be apprehended, and should be carefully guarded 
against, whenever the fever is violent, especially if the pulse runs very 
high, when there are urgent complaints of headache, when the restless- 
ness and agitation are very great, or when there is somnolence, with fre- 
quent startings or twitchings of the muscles. Convulsions sometimes 
occur without any previous warning, or after such slight signs of disorder 
as would fail to produce uneasiness in the parents or attendants. 

The symptoms produced by occasional indigestion generally continue 
until nature relieves the stomach by vomiting or diarrhoea, or until the 
remedies proper in the case, the most important of which are evacuants, 
have been administered. It happens not unfrequently, that symptoms of 
gastric or intestinal disorder remain for some days after the violence of 
the attack has subsided, and in some instances the disturbance is so great 
as to occasion gastritis, entero-colitis, or dysentery. 

Habitual indigestion in children who have completed the first dentition, 
is not at all an uncommon affection. It is a condition analogous to, if 
not identical with, the dyspepsia of the adult. The symptoms of this form 
are the following. The general appearance of the child is delicate, as 
shown b}^ a pallid or sallow tint of the skin, instead of the ruddy com- 
plexion of health, by thinness and want of proper development of the 
limbs and trunk, and by softness and flaccidity of the muscular tissues. • 
There is an habitual air of languor and listlessness, with absence of the 



320 INDIGESTION. 

usual gayety aucl disposition to play natural to the age. and the child often 
complains of being tired. The appetite is feeble or uncertain, being some- 
times absent, and at other times too great : or it is peculiar, there being 
a willingness to eat of dainties, but a refusal of food of a simple character. 
The tongue presents nothing peculiar. It is. however, more frequently 
somewhat furred than clean and natural. The temper is usually irritable 
and uncertain. The child rarely sleeps well ; on the contrary, the nights 
are restless and much disturbed, the sleep being broken and interrupted 
by turning and rolling, by moaning or crying out. and by grinding of the 
teeth. These latter symptoms, together with picking at the nose, which 
is a frequent accompaniment, are almost always referred by the parents 
and nurses to worms, and it is often impossible to convince them to the 
contrary, even though frequent and violent doses of vermifuges have failed 
to show the existence of entozoa. The state of the bowels is uncertain. 
In some instances they are very much constipated, requiring frequent 
doses of laxatives, or careful regulation of the diet, to keep them soluble ; 
in others they are inclined to be loose, and when this happens, the stools 
are often lienteric. In others, again, constipation and diarrhoea alternate. 
The abdomen is usually natural, or somewhat enlarged from flatulent dis- 
tension ; complaints of pain are not uncommon. This form of indiges- 
tion, like dyspepsia in the adult, is generally a very chronic affection, 
seldom lasting less than several weeks or months, and sometimes persist- 
ing for years. 

Diagnosis. — The occasional indigestion of infants is not likely to be 
mistaken for any other complaint. The suddenness of the attack, the 
character and quantity of the matters ejected from the stomach, the ab- 
sence of symptoms indicating the invasion of any other disorder, the short 
duration of the symptoms, and the rapid recovery, all render the true 
nature of the case very clear. That which occurs in older children, on 
the contrary, is not so easy of diagnosis. In many cases the invasion is 
not unlike that of scarlet fever. The vomiting, the rapidity of the pulse, 
the great heat of the skin, and in some cases a certain suffusion of the 
integument dependent on the activity of the circulation, all render the 
case doubtful for some hours, or for a day. after which time the difficulty 
ceases, from the development of the symptoms peculiar to the disorder. 
We believe that not a few cases of simple angina are mistaken for indi- 
gestion, owing to the absence of complaints of sore throat, and the neglect 
of the physician to examine that part. In such cases the vomiting and 
sudden attack of fever are ascribed, for the want of another mode of ex- 
plaining them, to gastric derangement. The diagnosis can be made only 
by examination of the fauces. The diagnosis of indigestion accompanied 
by convulsions will be considered in the article on the latter atfection. 

The habitual indigestion of infants is not likely to be confounded with 
any other disease. The absence of fever, of tenderness of the abdomen 
on pressure, or other acute symptoms, all indicate the dependence of the 
disorder on functional distress of the stomach. The same remarks apply 
to this form of the disease occurring in older children. Nevertheless, the 
practitioner should never neglect to make a careful examination, both of 



TREATMENT. OZI 

the physical and rational signs, of all the important organs of the body, 
as it sometimes happens that latent disease of some one of them is the 
cause of the gastric difficulty. 

Prognosis. — The prognosis of occasional indigestion is nearly always 
favorable. It is rarely a dangerous disorder, unless accompanied by con- 
vulsions, or some other sign of violent disturbance of the nervous system. 
Under the latter circumstances, the prognosis should be very cautious, as 
the termination is not unfrequently fatal in consequence of injury done 
to the nervous centres. It should be recollected also that this form of 
indigestion sometimes becomes the exciting cause of inflammation of the 
stomach or intestines, in which event the prognosis will be that of those 
diseases. 

Habitual indigestion in infants is a serious complaint, and ought al- 
ways to awaken the solicitude both of the physician and parents ; for 
though a simple functional disease of the stomach is not probably often 
fatal, it is exceedingly apt to prove so by the induction of gastritis, 
chronic enteritis, entero-colitis, or thrush, or by its laying the system 
open to other diseases, and rendering it less able to withstand them 
should they happen to occur. In older children it is not, according to 
our experience, so dangerous a malady. We have never, as yet, seen it 
terminate fatally. 

Treatment. — The treatment of occasional indigestion in infants ought 
to be very simple. The child has generally relieved itself by vomiting 
before the physician is called. If, however, it continues pale and languid, 
with vomiting or retching, after the stomach seems to have been emptied, 
the proper plan is to make use of remedies to calm the irritability of that 
organ. This can almost always be accomplished by giving a teaspoonful 
every ten or fifteen minutes of a mixture of lime-water and milk, consist- 
ing of one-third milk to two-thirds lime-water, or of equal proportions of 
each, or the same doses of a mixture consisting of equal parts of lime- 
water and cinnamon-water. At the same time a small mustard plaster, 
weakened with wheat flour, or flannels wrung out of hot brandy and 
water, may be applied to the epigastrium, or a warm Indian mush poul- 
tice, in a flannel bag, laid over the whole abdomen. Should these means 
fail to relieve the sickness, from half a drop to a drop of laudanum, or 
ten drops of paregoric, may be administered, and repeated, if necessary, 
in two hours. The child generally recovers its usual health after the 
sickness has entirely ceased. If, however, it remain fretful and uneasy, 
if it cry much as though in pain, it is probable that a portion of aliment 
has passed, in a partially or wholly undigested state, into the intestine. 
The suspicion will be confirmed if the abdomen is found, upon palpation 
and percussion, to be swelled, hard, and resonant from flatulent collec- 
tions in the bowels. Under these circumstances, a laxative ought to be 
given. The best dose is half a teaspoonful or a teaspoonful of castor oil, 
a teaspoonful of simple or spiced syrup of rhubarb, or, if there have been 
evidences of an acid state of the stomach, about a quarter of a teaspoon- 
ful of the best magnesia. 

The occasional indigestion of older children demands a different and 

21 



322 INDIGESTION. 

more energetic treatment. After ascertaining that the child has eaten 
something indigestible, we should inquire whether there has been vomit- 
ing. If there has been none, or if only slight, it will be proper to give 
an emetic immediately. The best one under the circumstances is ipecac- 
uanha. This rarely fails to produce a full effect, and does not perturbate 
the system, or irritate the stomach, like tartar emetic. It may be given 
either in powder or syrup. The dose is familiar to every one. If the 
ipecacuanha be not at hand, we may use hive syrup, which is kept in al- 
most every house, or a teaspoonful of powdered alum in honey or mo- 
lasses, to be repeated, if necessary, in fifteen minutes. Alum is less apt 
to fail than either ipecacuanha or hive syrup. If the child continue un- 
well after the operation of the emetic, which is often the case, and par- 
ticularly if the fever be considerable, a purgative should be given as soon 
as the stomach will bear it. The best dose is castor oil, which is the most 
speed}' and least irritating. It may be given in orange juice, which forms 
an excellent vehicle, or, if the child is old enough, in the froth of beer or 
porter. A dessert-spoonful is generally enough. If the oil cannot be 
taken, we may give infusion of senna and mauna, the fluid extract of 
senna mixed with spiced syrup of rhubarb, syrup of rhubarb alone, mag- 
nesia, to be followed by lemonade, salts and magnesia, or the former 
alone, or, lastly, a seidlitz powder. If the fever continue, and the ca- 
thartic fail to operate in four or six hours, a purgative enema ought to be 
given to hasten its effect. A bath at about 96° or 97° will almost always 
be found useful in these cases. The child should be kept in the bath from 
eight to twelve or fifteen minutes. The only circumstances which form 
an objection to this remecty are the facts of the patient being so irritable, 
or so fearful of the water, as to make it necessary to contend with him 
in order to succeed in using it. When this is the case, it had better not 
be erupkyved, and sponging with tepid water and spirit should be substi- 
tuted. If the child complains of pain in the stomach, the application of 
a warm mush poultice over the epigastrium or whole abdomen will be 
found of much service. 

When, in this form of indigestion, the febrile reaction is violent, as it 
often is, and particularly when there are signs of great disturbance of the 
nervous system, consisting of excessive agitation, complaints of severe 
headache, drowsiness, moaning or crying out in the sleep, or twitching 
and jerking of the muscles, the physician should beware of a convulsive 
attack. In such cases as these, the patient ought to take a purgative dose 
of calomel (from two to three grains), or a dessert-spoonful of castor oil, 
have a warm bath at once, and soon after an injection. The remedies 
ought to be prompt and energetic, for the case is pressing. A convulsion 
is alwa}' s a dangerous event in childhood, and should be prevented if pos- 
sible. If calomel has been given, a cathartic dose ought to be adminis- 
tered about two hours afterwards, in order to insure an action upon the 
bowels, and to carry the calomel out of the S3 T stem. These means rarely 
fail to afford relief in a few hours. The diet should be absolute during 
the violent stages of the attack, and the usual diet is to be resumed only 
by degrees. The drinks ma} T be plain water or gum-water, taken cold. 



TREATMENT. 323 

It not unfrequentiy happens that occasional indigestion is followed by 
gastritis or enteritis, or b} T habitual indigestion lasting for weeks or even 
months. These different sequelae must be treated according to the plan 
proper for each. 

The habitual indigestion of both infants and older children, requires a 
very different treatment from the occasional or accidental form. In both 
the indications are nearly the same. The most important are very careful 
regulation of the diet in all its details, the use of tonics and stimulants 
to restore tone and vigor to the digestive function, the employment of 
remedies to correct the state of the bowels, whether they be relaxed or 
constipated, and attention to securing the child proper exercise, exposure 
to the air, and suitable clothing. 

If the symptoms of the disorder occur in a child at the breast, the milk 
of the nurse should be carefully examined, in order to ascertain whether 
it be good. If found to possess airv unhealthy qualities, the nurse ought 
to be changed at once. Attention to this point alone will almost certainly 
cure the child. It needs no other remedy. 

If the patient is fed wholly or in part, it is essential to regulate the 
diet to suit the state of the digestive function. Milk ought in all cases 
to form the basis of the food, unless it has been found by patient trial to 
be absolutely repugnant to the stomach. We have often found that in- 
fants who had been thought quite incapable of digesting cow's milk, could 
do so very readily when it was very much weakened with water. The 
usual proportions for an infant of a few months old, are half and half, or 
two parts milk for one of water. When these are found to disagree, it is 
well to try three, or even four or five parts of water to one of milk, and 
if the stomach digest this, as it often will, the proportion of milk may be 
slowly and cautiously increased to the usual standard. If we conclude 
that milk cannot be digested by the child, it is best to try cream. Of this, 
one part to three or four of water, may be given. When neither of these 
can be taken, some of the farinaceous substances may be tried ; arrowroot, 
sago, barley, tapioca, oatmeal, or rice. We are clearly of opinion, how- 
ever, that these articles prepared with water alone, never agree with 
children when they are continued for any considerable length of time. 
Some infants of six or eight months old, it may be remarked, who cannot 
digest more than very small quantities of milk, will take and digest well, 
very delicate broths made of chicken or mutton, or small quantities of 
the lightest meats, as mutton, chicken, or very tender beef, minced up 
extremely fine, and given by teaspoonfuls. 

In cases of this kind we have found a diet consisting of gelatine, milk, 
cream, and arrowroot, prepared in the manner directed in the article on 
thrush (see p. 304), to suit better than anything else. We have met with 
several children, and with two in particular, whom it was necessary to 
feed to the amount of a pint or a pint and a half a cla} T , in addition to 
their being nursed occasionally, who could take neither milk and water, 
cream and water, milk and arrowroot, oatmeal gruel, rice gruel, nor in- 
deed anything that was tried, without vomiting, colic, and severe diarrhoea, 
who digested perfectly well and throve admirably upon the preparation 



324 INDIGESTION. 

alluded to. We have now used it during several 3 y ears, and have recom- 
mended it for a great many children, and do not hesitate to say that it 
agrees with a larger number than any diet we have employed or seen 
emplo} T ed. 

The diet of older children laboring under chronic weakness of the di- 
gestive function is as important as that of infants. Two chief ends should 
always be borne in mind in selecting it, digestibility and nutritiousness. 
The former is all-important, for without it, the stomach, constantly irri- 
tated by improper food, has no chance of regaining its tone, while the 
latter is necessary in order to sustain the strength of the child, and allow 
it to cany on its growth. We have generally found it most prudent, and 
often really necessary, to specify as to the substances to be given at each 
meal. The morning and evening meal ought to consist of bread and milk, 
mush and milk, or of milk, warm water and sugar (called in this country 
children's or cambric tea), and bread and butter, and nothing else in 
most of the cases. It is sometimes proper to allow a soft-boiled egg : 
particularly if the child be very fond of it. The dinner ought to consist 
of light broths containing rice, with bread or toast, or of the plain meats, 
as mutton, beef, chicken, turkey, birds, or fine game. J^o vegetable ought 
to be allowed in most of the cases except rice, as all others, even the potato, 
are very apt to disagree. We believe that the potato is more digestible 
when roasted than when boiled. If the child require an3^thing between 
breakfast and dinner, it may have what is allowed at breakfast, or dry 
bread and nothing else. There are various articles of diet which should 
be absolutely forbidden, amongst which are hot and sweet cakes, and hot 
bread of all kinds ; sausages, not unfrequently given to children in this 
country ; corn-beef, ham, veal, pork, goose, ducks, fish ; all manner of des- 
sert, excepting rice-pudding, or curds-and-whe} r , often called junket; sweet- 
meats, candies, fruits, except some of our finest summer ones ; and to 
conclude, everything which long observation and experience have shown 
to be unsuitable to a dyspeptic stomach. 

It is sometimes very difficult to find anj'thing to agree well with the 
child. In one case of a child three years old that came under our obser- 
vation, neither milk, bread, nor meat, could be taken. The caseine of 
milk seemed to be absolutely indigestible, as it would be rejected from 
the stomach many hours, or even a day or two after the milk had been 
taken, in the form of masses of diy, fibrous cheese, of an oblong shape, 
nearly or quite as large as a peach-stone. After trying various articles, 
we found that the child digested raw 0} T sters, soda-biscuit, and rennet- 
whey, and upon these articles alone she lived for two weeks, at the end 
of which time she had improved so much as to be able to take the white 
meat of chicken very finely minced. She gradually regained her previous 
health. 

After regulating the diet, such remedies as tend to invigorate the diges- 
tive functions ought to be prescribed. The most important of these are 
the vegetable and mineral tonics, and mild stimulants. We have found 
quinine, iron, and small quantities of port wine or brandy, to succeed 
better than anything else. To a child under two years old, from a quarter 



TREATMENT. 325 

to half a grain of quinine, and to one over that age, a grain, may be given 
three times a day, and continued for two, three, or four weeks. It is best 
given to young children diffused, without being dissolved, in a mixture 
of equal parts of syrup of gum and ginger ; while to those who are older it 
may be administered in pill. The best preparations of iron are the syrup 
of the iodide, or the pure metallic iron prepared with hydrogen. Of the 
former, half a drop to one drop for infants, and from two to four drops for 
older children, may be given three times a day; of the latter a quarter of 
a grain for infants, and half a grain to a grain for those who are above that 
age, may be given three times a day. The metallic iron is best adminis- 
tered in pill, or suspended in syrup of gum arabic. When there is any 
suspicion of a scrofulous taint in the child's constitution, or when it is 
disposed to have chronic irritations, excoriations, or ulcerations of the 
nostrils, otorrhcea, or papules or pustules about the eyelids or other parts 
of the body, it is useful to give the iron in compound syrup of sarsapar- 
illa, of which half a teaspoonful three times a day is quite enough. Under 
these circumstances, and particularly when the dyspeptic condition is 
accompanied with frequent nausea or occasional vomiting, with frontal 
headache, and with constipation, seeming to indicate a disposition to 
tubercular deposit in the system, we have found cod-liver oil the most 
efficient of all the remedies that we have tried. It has often removed 
with great rapidity the dyspeptic symptoms, invigorated the general 
health, and, in fact, restored the patient to health. The dose is from 
half a teaspoonful to a teaspoonful twice or three times a day, at the age 
of six or eight 3'ears. It is best taken in a small quantity of malt liquor, 
or floating on strong mint-water or sj^rup of ginger. In very young chil- 
dren, and in older ones also, when the latter refuse to take it in the or- 
dinary methods, the following formula for its administration will be found 
one of the best : 

R.— 01. Jec. Aselli, fgss. 

P. G. Acaeiae, q. s. 

01. Cinnamomi, vel 01. Gaultheriae, . . gtt. vj. 
Sacch. Alb., . . . . . . . q. s. 

Aq. Cinnamomi, ..... ad f^iij. 

Ft. mistura. 
Dose, a dessert-spoonful three times a day, after eating. 

In connection with these remedies, a little port wine or brandy, and 
the former is preferable in children over a few years old, on account of 
the possibility of their contracting a taste for the brandy, may be allowed 
twice or three times a day, or at dinner only. To young children, one or 
two teaspoonfuls of brandy may be given in the course of the clay, mixed 
in water ; of the port wine, from a teaspoonful to a tablespoonful, accord- 
ing to the age and strength of the patient, may be repeated morning, 
noon, and night. 

If the bowels are inclined to constipation, they should be kept soluble 
by laxative enemata, and by the use of rhubarb or aloes ; when relaxed, 
the frequency of the discharges may be controlled by the cretaceous mix- 



326 SIMPLE DIAERHGEA. 

ture, by anodyne enemata given once or twice a day, by the aromatic 
syrup of galls (to be described under the head of entero-colitis), or by 
some of the astringents in common use. 

In all cases of chronic indigestion in children, it ought to be regarded 
as an essential part of the treatment to secure to the patient a proper 
amount of exercise in the open air. In summer the child should pass 
several hours of every day in the air. It ought, indeed, if the heat of the 
sun can be avoided hy proper shade, to pass the whole day in this way. 
In winter it is, of course, impossible to carry this s} T stem to the same 
extent, but the child should nevertheless be taken out at least once a day ; 
this may be done in the coldest, and even in damp weather, if sufficient 
clothing be worn. If a child comes back from a walk with warm limbs, 
and with its cheeks in a glow, there is little danger of cold. The quan- 
tity of clothing must depend on the constitution and idiosyncrasy of the 
patient. Some need twice as much as others. The proper amount is best 
determined by the temperature and coloration of the surface after a walk. 



AETICLE II. 

SIMPLE DIAPvRHCEA. 

Under this title we shall describe a mild form of diarrhoea to which 
children are very subject, in which the pathological condition appears to 
be one of mere functional disorder, or of very moderate hyperaeinia or 
catarrh of the intestinal mucous membrane. We might, indeed, assume, 
with some, that the disorder is at all times one of mild catarrh of the 
bowels, but we deem it best, in a practical point of view, to consider it 
as being sometimes one of functional disturbance only, since many ob- 
servers of high authority declare that they meet with cases of even fatal 
diarrhoea in which no anatomical alterations are found after death, and 
since we ourselves have met with so many cases in practice which follow 
a different course in symptomatology, duration, and their effects upon the 
constitution, from the form of disease which we shall treat of as entero- 
colitis or inflammatory diarrhoea. 

Causes. — The causes of the disease during infancy are unfavorable 
hygienic conditions, as the habitation of unwholesome, ill-ventilated, 
damp, and filthy dwellings, or of contracted and crowded quarters of 
cities and towns ; an unhealthy state of the milk of the nurse ; the use of 
artificial diet at too early an age, especially that of an improper kind ; 
cold ; dentition ; and lastly, great atmospheric heats. The most impor- 
tant of these are improper alimentation, by which we mean the use of arti- 
ficial diet, and particularly one consisting chiefly of farinaceous substances 
to the exclusion of a proper amount of milk, and dentition. For a fuller 
account of the influence of these different circumstances on the digestive 
organs of children, the reader is referred to the remarks on the causes of 
entero-colitis j and to the article on thrush. 



causes. 327 

The chief causes of the disease after the first dentition are, according 
to our experience: the habitual use of improper food ; the loss of diges- 
tive power, which often follows a severe indigestion, or an attack of some 
acute disease ; the debility of constitution which attends sudden and rapid 
growth; the want of proper exercise and exposure to the air; the predis- 
position which exists in some children from hereditary causes ; and the 
disturbing influence of the second dentition. 

The sj-stem of indiscriminate diet allowed to children in this country 
is, it seems to us, a fruitful cause of gastric and intestinal complaints. 
We believe that, as a general rule, children over two and three years of 
age, are allowed amongst us to eat of the food prepared for the older 
members of the family. Now, anj^ one who will reflect upon the variety 
of dishes habitually placed upon an American table, ought not to be sur- 
prised to see children permitted a choice amidst such profusion, pale, 
thin, delicate, exposed to frequent indigestions, attacks of diarrhoea, and 
entero-colitis, to gastric fevers, and the host of minor ills attendant upon 
feeble digestive powers. We are acquainted with some families in this 
city, the children of which, from the age of two years, are allowed habitu- 
ally to breakfast upon hot rolls and butter, hot buckwheat cakes, hot 
Indian cakes, rice cakes, sausages, salt fish, ham, or dried beef, and cof- 
fee or tea ; and to dine upon a choice of various meats and a great variety 
of vegetables, which latter they often prefer to the exclusion of meat, and 
then to make a rich dessert of pies, puddings, preserves, or fruits ; and 
lastly to make an evening meal of tea and bread and butter, almost always 
relished, as the term is, with preserves, stewed fruits, hot cakes of some 
kind, or with radishes, cucumbers, or some similar dish. Add to such 
meals as the above, the eating between whiles of all kinds of candies and 
comfits, which man} 7 children here regularly expect in larger or smaller 
quantity, cakes both rich and plain, fruits to excess and at all hours, 
from soon after breakfast to just before going to bed, raisins and almonds, 
and nuts of various kinds, and the wonder is, not that we are a pale, thin, 
dyspeptic, and anxious-looking race of people, compared with Europeans, 
but that we have any health at all, when our children are allowed to make 
use of the indiscriminate and unwholesome diet just described. Such a 
s}-stem undoubtedly occasions frequent attacks of the disease under con- 
sideration, and unless the diet be changed early in the attack, it is very 
apt to become chronic. It has been stated that simple diarrhoea some- 
times followed as a consequence of indigestion. We have known such a 
result to occur in children previously in fine health, and to continue for 
several weeks or months. In these instances, the disorder appears to 
depend in good measure on the loss of the digestive power of the 
stomach. This seems proved by the great influence which the character 
of the food has upon the malady, which is always aggravated by the use 
of any articles except those universally acknowledged to be the most di- 
gestible, and also by the frequent coexistence of lienteiy when the food is 
not of the lightest kind. 

We have several times met with cases which we could ascribe to no 
other cause than debility and want of power of the digestive organs, de- 



328 SIMPLE DIARRH(EA. 

pendent upon too rapid growth. That sudden and rapid growth may pro- 
duce feeble digestion, or, in other words, a dyspeptic state, is, in our 
opinion, proved by the following consideration. It is attended with loss 
of appetite, emaciation, paleness, languor, and weakness, and frequent 
attacks of diarrhoea, or a chronic form of that disorder ; all of which 
symptoms are greatly influenced by the regimen of the child, and are 
most readily removed by attention to that point, and by the use of tonics 
and stimulants. 

The other causes enumerated need but little comment. We will merely 
remark that we have several times observed a predisposition to weakness 
of the digestive organs, transmitted apparently from parent to child. As 
to the influence of the second dentition, we have no doubt that it is a fre- 
quent cause of the complaint, and we believe that it is too little attended 
to by practitioners. 

Anatomical Appearances. — It has alread}^ been stated that we look 
upon this disorder as one of purely functional disturbance in many in- 
stances. We are led to take this view by the fact that it is so often un- 
attended by any of the ordinary signs of inflammatory action, and because 
some very competent observers affirm that they have failed to find in a 
certain proportion of cases of fatal diarrhoea, any lesions appreciable to 
the senses. Thus, M. Billard says {Mai. des Enfants, p. 392): "Many 
children at the breast have diarrhoea without enteritis ; they lose color, 
become etiolated, fall into a state of marasmus, and yet at the autopsy 
not a trace of inflammation of the intestines is found." M. Bertin {Mai. 
des Enfants, 2eme ed., p. 574) states that of 57 cases of gastro-intestinal 
disease observed by himself, there were 4 in which not a trace of inflam- 
mation, or any other appreciable lesion of the digestive tube, could be 
found. MM. Rilliet and Barthez, in their first edition (t. i, p. 491) as- 
sert that in about every twelve children affected with more or less abun- 
dant diarrhoea, and in whom we might expect to find colitis, there will be 
one in whom the gastro-intestinal tube will be found in a state of perfect 
integrity. They add that this conclusion is deduced from a comparison 
of nearly three hundred autopsies. We do not find this statement given 
in their second edition, but we do find there (t. i, p. 693) the following 
paragraph: "Quite frequently, especially in early infancy, in cases in 
which the sjanptoms have pointed to some disease of the gastro-intes- 
tinal tube, an autopsy reveals no lesion of the solids, or only changes of 
minimum importance. The secretions alone are vitiated." One must 
suppose, therefore, that the class of cases which we describe as simple 
diarrhoea, are sometimes quite independent of any anatomical changes in 
the tissues, recognizable hy our ordinary methods of examination, or that 
those changes are so slight and so evanescent as to disappear after death ; 
or that they are those only of the mildest forms of catarrhal inflammation. 
It is not unlikely, it seems to us, that further and more minute investiga- 
tion, especially with the microscope, will reveal tissue-changes which are 
not discoverable by the unassisted senses. 

When the anatomical changes, constituting the catarrhal state, are 
found in children who presented during life the symptoms of simple diar- 



SYMPTOMS. 329 

rhoea. they will be such as are described by Niemeyer in the following 
passage: "Catarrh rarely affects the entire intestinal canal. It is most 
frequent in the large intestine, less so in the ileum, and rarest in the jeju- 
num and duodeum. The anatomical changes left in the cadaver by acute 
catarrh, are sometimes pale, at others dark redness, swelling, relaxation, 
and friability of the mucous membrane, which is sometimes diffuse, at 
others limited to the vicinity of the solitary glands, and of Peyer's 
patches, and a serous infiltration of the sub-mucous tissue. Occasion- 
ally, after death, the injection has entirely disappeared, and the mucous 
membrane appears pale and bloodless. Swelling of the solitary glands 
and glands of Peyer is an almost constant appearance ; they distinctly 
project above the surface of the mucous membrane. The mesenteric 
glands also are usually found hyperaemic and somewhat enlarged. The 
contents of the intestines consist at first of plentiful serous fluid, mixed 
with detached epithelial and young cells, subsequently of a cloudy mucus, 
which is adherent to the wall of the intestine, and contains epithelial 
structures." 

The best description that we are acquainted with of the anatomical 
appearances found in the intestines in fatal cases of diarrhoea, not in 
children, to be sure, but in adults, is that given by Dr. Woodward in his 
work on Camp Diseases (Philadelphia, 1863). In that work (page 216), 
under the head of simple diarrhoea, he says that this form of diarrhoea is 
to be regarded as usually the result of irritation of the intestinal mucous 
membrane, produced by the ingestion of improper food, or other causes 
mentioned, and expressing itself in increased secretion throughout the 
intestinal tract. The irritation, he goes on to say, may even amount to 
inflammation. Opportunities for post-mortem examination, occur but 
rarely. " They reveal little that bears on the nature of the disease, except 
congestion of the intestinal vessels of variable intensity." At page 246, 
will be found a description of the histology of the intestinal lesion in 
chronic diarrhoea, including the changes observed in specimens but mode- 
rately diseased, which latter would probably be the analogue of what we 
might expect to find in the simple diarrhoea of children we are now 
describing. We must refer the reader to the work itself, as the passage 
is too long to be quoted in full here ; but we cannot help thinking that 
Dr. Woodward's descriptions would apply also to the changes induced 
in children by like causes, and leading to similar forms of disease. 

Symptoms. — We shall describe first the symptoms of simple diarrhoea 
in infants, and afterwards those which characterize the disorder in older 
children. In infants the appearance of the diarrhoea is usually preceded 
or accompanied by slight disturbance of the temper and comfort of the 
child. There is some degree of restlessness, peevishness, and disposition 
to cry ; the child sleeps less than usual, and often starts and moans 
during sleep; all of which symptoms are more marked, as is the case in- 
deed in nearly all the ailments of children, during the night. Though 
the symptoms described are observed from time to time, and particularly 
during the night, they are not always present, as the infant will occasion- 
ally through the day seem perfectly well and comfortable, with the excep- 



330 SIMPLE DIARRHOEA. 

tion, perhaps, of slight paleness and languor, almost always perceptible 
upon its countenance. There is no fever in these cases, or at least noth- 
ing more than unusual warmth of the hands, feet, and abdomen at night. 
If a marked febrile reaction take place, there would be reason to suspect 
the existence of some degree of entero-colitis. The mouth often becomes, 
after a few da}'S, a little warmer and less moist than usual ; the tongue is 
generally moist and only slightly coated ; and the appetite is commonly 
diminished, as shown b} r the child's nursing with less eagerness and at 
longer intervals than before. In very mild cases the stools are at first, 
and sometimes throughout the attack, feculent; the only differences from 
their ordinary characters are that they are more frequent, thinner, more 
copious than usual, and that the odor is changed so as to become acrid 
and offensive. In severe cases, they contain less feculent matter, become 
yet more fluid and sometimes watery, and exhibit small particles of a 
greenish color scattered through them ; or the whole of the discharge is 
of a deep green color, and it is intermixed with portions of mucus. In 
many of the cases, whitish lumps, evidently consisting of undigested 
curd, are observed mixed with the other substances upon the napkin. 
The number of stools varies from two, three, or four, to six or eight in 
the twenty-four hours. The number last mentioned is seldom exceeded, 
so long as the diarrhoea remains simple. The abdomen is seldom dis- 
tended or painful to the touch. The general appearance of the child 
almost always shows the effects of the malady upon the constitution after 
a few days. The countenance becomes paler and thinner ; the eyes look 
somewhat hollow ; the edges of the orbits are more defined, and often 
present a pale bluish circle ; slight emaciation takes place, and the flesh 
of the child becomes softer and more relaxed than before the attack. The 
duration of the disorder is generally short, as it seldom lasts more than 
three or four dsijs or a week. It may terminate in complete restoration 
to health, without having exposed the life of the child to danger, or, if 
the causes which gave rise to it continue in action, if the child is of deli- 
cate constitution or the treatment not correct, and especially if this is of 
too perturbating a character, it is very apt to run into entero-colitis and 
expose the patient to all the dangers of that disease. 

In older children (after the first dentition), the disease is much less fre- 
quent than in infants, and presents a different train of symptoms. Often 
it is nothing more than a slight disorder of the bowels, amounting to 
three, four, or five stools, thinner and more abundant than usual, accom- 
panied hy slight colicky pains, and unattended by fever or other signs of 
sickness, which, after continuing one, two, or three days, ceases, and the 
child regains its usual health. Some children are particularly liable to 
these attacks, and suffer from them every few weeks, or after au} T indis- 
cretion in diet ; whilst in others the}^ are rare, let the diet be what it may. 

There is another form of simple diarrhoea, however, of which we have 
seen nine cases, much more troublesome than the one just described. It 
occurs in children from two and a half to seven and eight 3 r ears of age, 
lasts a considerably longer time, and is much less under the control of 
remedial measures. This form of the disease has never, in the cases that 



DIAGNOSIS — PROGNOSIS. 331 

we have seen, been accompanied by fever, or b} r any constitutional symp- 
toms rendering it necessary to confine the child either to the bed or house. 
The only symptoms besides the diarrhoea which we have observed, have 
been some degree of paleness and moderate emaciation ; slight weakness, 
shown by an indisposition on the part of the child to play with its usual 
spirit, by an inclination to lie about from time to time through the day 
on the sofa or floor, and by complaints of " being tired ;" irritability of 
temper and peevishness ; irregular appetite ; picking of the nose ; and 
restless, disturbed sleep at night, attended with moaning, crying, start- 
ing, and grinding of the teeth ; all of which sy mptoms generally convince 
the mother that the child is suffering from worms. The abdomen is some- 
times slightly tumid, but remains natural as to tension, and is not painful 
on pressure. There is no pain except slight colic in some cases. The 
stools have generally numbered from three to five, and in a few cases as 
man}- as six or eight a day. They are semifluid in consistence, often of 
a very offensive odor, and consist usually of feculent matter, which is 
sometimes clay-colored, more frequently dark brown, and, in other in- 
stances, deep yellow or orange in color. They are often also of a frothy 
character. In two of the nine cases that we have seen, there was lientery 
whenever the aliment was otherwise than of the lightest and most digest- 
ible kind. In all, the diarrhoea was evidently greatly influenced by the 
diet, showing, it appeared to us, a manifest dependence of the malady 
upon the condition of the stomach, which seemed to have lost to a great 
degree its digestive power. 

The course of the disease in this form was variable. In some it would 
last a few weeks, and then, under the influence of diet and remedies, 
cease, to recur and run the same course after a short period. In others 
it has lasted a much longer time in spite of all treatment that we at- 
tempted. In three of the cases it continued between three and four 
months, with occasional slight remissions, brought about apparently by 
remedies which a day or two after would lose their effect. In two others 
it lasted about two months ; in another six weeks, in another a month ; 
in the remaining two cases the exact duration is not recollected. 

Diagnosis. — The diagnosis of simple diarrhoea will rarely present any 
difficulties, since there is nothing with which it could be confounded, 
except the diarrhoea from tubercular ulceration of the bowels, or entero- 
colitis. From the former it is to be distinguished by the history of the 
case, and by the signs of tuberculosis in other parts of the economy; from 
the latter, by the absence of signs of inflammatory action. 

Prognosis. — The prognosis is favorable so long as the disease remains 
simple. The physician should never forget,, however, the disposition which 
is inherent in it to pass into entero-colitis, nor fail to make the possible 
occurrence of this transition one element in his prognosis. During in- 
fancy it is always more serious than after that period, from the feebler 
power of resistance on the part of the constitution at that age to disease, 
which undoubtedly allows this simple affection to prove fatal in some in- 
stances, probably from the shock to the nervous system. After infancy 
it is rarely a dangerous disorder, both because of the greater stamina 



332 SIMPLE DIARRHCEA. 

existing at that age, and from the fact that the disposition to the exten- 
sion of disease is less strong. 

Treatment. — The prophylactic management of simple diarrhoea is the 
same as that which is proper for entero-colitis, and as that affection will 
be treated of at considerable length in a future article, we must on ac- 
count of our limited space, refer the reader there for information on this 
point. 

After the disease is established, the treatment must consist first in at- 
tention to the diet, exercise, and state of the gums of the child. In many 
cases, careful regulation of the diet and exercise, and lancing the gums 
when they are much distended and vascular from the pressure of the 
advancing teeth, will suffice to arrest the disorder in a few da} T s, without 
the necessity of resorting to drugs, which ought certainly to be avoided 
whenever it is possible to do so. If the child is at the breast, we must 
ascertain whether the milk of the nurse is good, b} r inquiry as to its ap- 
pearance, specific gravity, reaction, and b}^ examination with the micro- 
scope, and by reference to her health, diet, temper, &c, all of which cir- 
cumstances more or less affect the mammary secretion. If we conclude 
that the milk is good, or that it has been disturbed in its healthy prop- 
erties only b}'' a transient cause, the child must be continued at the breast, 
with the precaution, however, of not allowing it to nurse quite so much 
as usual. An infant suffering from any kind of diarrhoea, had better be 
restricted entirely to the breast, unless it be clear that the supply of milk 
is quite insufficient. If we determine that the milk is unhealthy, the 
nurse must either be changed, or the child weaned ; of course the former 
alternative is infinitely preferable if the child is under a } T ear old, or even 
under eighteen months, if it seem to have a rather delicate constitution. 

If the case occur in a child alreadj^ weaned, or in one fed partly on 
artificial diet, the regulation of the kind, preparation, and quantity of ali- 
ment is of the utmost consequence. It ought to consist chiefly of milk 
or cream weakened with water, unless it has been clearly shown by pre- 
vious trial that these articles do not agree with the child. We prefer be- 
fore any kind of diet that we have ever employed, or known to be em- 
ployed, that made from cow's milk, cream, arrowroot, and gelatine, in 
the manner described at page 304. The proportions of the milk, cream, 
and arrowroot must vary with the age and digestive power of the patient. 
As a general principle, during the existence of diarrhoea, or at least in 
the earh 7 stage of it, and before the strength has been reduced by the dis- 
order, the proportions of cream and milk ought to be somewhat less than 
in health. Xot only so, but the total quantity of food in the day should 
be diminished, unless the ordinary amount seems to be really necessary 
for the sustentation of the strength. If it be found, after patient trial, 
that the child will not take, or does not digest this kind of food, we may 
try arrowroot or rice-water, with a little cream, or thin gruel or panada, 
alternated with very carefully prepared chicken or mutton water. If the 
child is six or eight months old, it often suits well to allow it a piece of 
juicy beef or a chicken-bone to suck, or from one to several teaspoonfuls 
of meat of chicken or mutton minced very fine. 



TREATMENT. 333 

For older children with a common attack of simple diarrhoea, the diet 
should consist for a few days of boiled milk with bread, of gruels made 
of boiled milk and arrowroot, rice-flour, sago, tapioca, or common wheat 
flour, and of small quantities of light broths. Meats are, for the time, 
improper, and all vegetables, with the exception of rice, yet worse. 

In the case of infants it is best to recommend a continuation of the or- 
dinary exercise, unless the weather be cold and damp. Indeed, in good 
weather, exposure to the air and proper insolation are more important 
during the existence of this disorder than even during health. The same 
remarks apply to older children, with the exception that they ought not 
to be allowed to fatigue themselves, particularly in warm weather, as this 
tends to aggravate the complaint. 

"When the disorder occurs in a teething child, the gums ought always 
to be examined b} T the plrysician, and if found swelled, vascular, of a deep 
red color, and hot, with the outline of the advancing tooth perceptible, 
they should be freely incised to the tooth. If, on the contrary, the tooth 
is too deep to be felt, and yet the gum is red and swelled, we would ad- 
vise only a slight and superficial scarification in order to relieve the 
tension. 

The therapeutical management of the disease should be as simple as 
possible. The fewer drugs we can succeed with in the gastro-intestinal com- 
plaints of infants and children, the better. When, however, the diarrhoea 
continues for some days in spite of attention to the points already men- 
tioned, and earlier if the discharges are either large, frequent, very watery, 
or weakening to the child, we must resort to some of the means which have 
been found most useful in checking the inordinate action of the bowels. 
The most important are a careful employment of laxatives, and the use 
of opiates and astringents. Formerly we generally commenced the treat- 
ment by the exhibition of a teaspoonful of castor oil, containing from 
half a drop to a drop of laudanum, for young infants, and two drops 
for older children ; but of late years we have usually preferred the spiced 
syrup of rhubarb, in a teaspoonful dose, with laudanum, as above recom- 
mended. Castor oil sometimes purges more than we like ; rhubarb rarely 
does so. These doses given for two evenings in succession have often- 
times sufficed to effect the cure. Dr. West recommends very highly in 
cases of simple diarrhoea, in which the evacuations, though watery, are 
fecal, and contain little mucus and no blood, small doses of the sulphate 
of magnesia and tincture of rhubarb. His formula at one year of age is 
as follows: f 

R. — Magnes. Sulphat., ..... gj, 

Tinct. Rhei, f^ij. 

Syr. Zingiber., . . . . . . fgj. 

Aquse Carui, f^ix. — M. 

Dose, a teaspoonful. 

We often use with excellent effect the sulphate of magnesia, with lauda- 
num, as follows : 



334 SIMPLE DIARRHOEA. 

R. — Magnes. Sulphat., 5J. 

Tr. Opii Deodorat., gtt. xij. 

Syrup. Simp., f<f ?s - 

Aqua3 Menth. vel Cinnamom., . . . f^ijss. — M. 
Dose, at one or two years a teaspoonful every two or three hours. For older chil- 
dren, the proportion of the magnesia and laudanum should be doubled. 

If the diarrhoea persists after these means have been used for two or 
three days, or gets rapidly worse, we must resort to some of the astrin- 
gents. The one most commonly employed is the chalk mixture, which is 
officinal in our Pharmacopoeia. A teaspoonful of this is to be given after 
each loose evacuation, or three or four times a clay. If the case prove 
obstinate, it will be found useful to add to each dose of the chalk prepa- 
ration, a small quantity of laudanum or paregoric, or some astringent 
tincture, the best of which is the tincture of krameria. When the chalk 
mixture fails entirely, powdered crab's-ej'es will sometimes succeed ; or 
we ma} 7 resort to the aromatic syrup of nut galls. The formulas and 
doses for both these remedies will be found in the article on entero-colitis. 
If the discharges are small and frequent, mixed with mucus and some- 
what painful, it will Jbe found that small opiate injections (from one to 
two drops of laudanum in a tablespoonful of prepared starch for young in- 
fants, and from three to six drops in double that quantity for older chil- 
dren), or the use of Dover's powder in combination with chalk or sugar 
of lead, will often succeed in arresting the disease. For further and more 
complete information in regard to astringents, we must refer the reader 
to the article on entero-colitis, wmere the} 7 will be full} 7 discussed. 

The chronic form of simple diarrhoea which we have attempted to de- 
scribe, occurring in children who have completed the first dentition, 
has always proved difficult to manage. From the experience we have 
had, we believe that the best mode of treating it is by proper regulation 
of the diet, and by the use of tonics and stimulants, and occasionally of 
opiates. We were led to adopt this plan in consequence of having failed 
entirely to control the symptoms by the treatment generally successful in 
simple diarrhoea, and by the opinion which we came at last to form, that 
the disease depended in great part on a loss of the digestive power of the 
stomach and duodenum. The diet must be adapted to the idiosyncrasies 
of the individual ; what we should seek is such a one as will be easily 
digested by the patient, the materials of which shall not appear in the 
stools, and one which does not manifestly increase, if it fail to moderate, 
the frequency of the discharges. The one Tthich we have found to succeed 
best, consists of boiled milk with stale bread for breakfast and tea, and 
the tenderest meats, as very fine beef, mutton, chicken, or birds, with rice, 
as the only vegetable, for dinner. If the child likes flour or rice pap, it 
may have either in place of the bread and milk. If it will take none of 
these, it may have milk, warm water and sugar, with bread ; or well-boiled 
mush with milk, or milk toast. Should it refuse the dinner recommended 
above, we may substitute delicate soup, or some of the milk preparations. 
Raw meat, given in the manner recommended in the article on entero- 
colitis, should also be tried, and will at times prove very beneficial. Be- 



TREATMENT. 335 

tween meals it ought to be allowed nothing but diy bread. All rich food, 
dessert, fruits, all vegetables except rice, candies and comfits, all kinds 
of cake and hot bread, in fact, eveiything except the articles which we 
have mentioned or similar ones, ought to be rigidly, systematically, and 
perseveringly forbidden. Until this has been done for many days, or for 
several weeks, the disease has always, according to our experience, obsti- 
nately persisted. 

We have already said that we have not found the ordinary remedies for 
simple diarrhoea to exert much effect upon this form of the disease. On 
the contrary, the treatment for dyspepsia, that is to say, a simple but 
nutritious diet, exercise, and the use of tonics and stimulants, has alwaj^s 
removed it in a longer or shorter time. The tonics which we have em- 
ployed are port wine, quinine and iron. From a dessert to a tablespoonful 
of port wine was usually given in water three times a day, in connection 
with iron. The preparations of iron used were Vallet's mass, of which 
from half a grain to a grain was given in pill three times a clay ; the solu- 
tion of iodide of iron in the dose of first one, and then from two to four 
drops, three times a day, or the solution of the nitrate of iron in the 
dose of from two to five drops, three times a day, in water, continued 
for one or two months. We have sometimes combined with each dose of 
the solution of iron, a drop of laudanum, especially if there were pain; 
or the opiate might be given by injection every evening. The quinine 
was generally administered alone in the dose of a grain three times a 
day, for one, two, or three weeks. It has not, however, proved so useful 
as port wine and iron. 

Another tonic which we have found very useful in some cases of this 
kind, of late years, is one containing nux vomica and compound tinc- 
ture of gentian, as follows : 

R. — Tr. Nucis Yomic, fgss. 

Tr. Gentian Comp., ...... fgiij. 

Syrup. Simp., fgv. 

Aquse, f^ij.— M. 

Dose, a teaspoonful three times a day after meals, for children of three or four 
years of age. 

Wine of pepsine, in half teaspoonful doses, three times a day, is also a 
good remedy in such cases. 

In the case attended with all the symptoms usually thought to indicate 
worms, the use of wormseed oil was followed by the expulsion of several 
very large lumbricoides. The child did not recover, however, for some 
weeks afterwards, and not until he had taken port wine and quinine for a 
considerable period. In other cases in which the verminous symptoms 
were also strongly marked, and in which the same remedy was given, no 
worms were expelled. 



836 GASTRITIS. 



SECTIOX II. 

DISEASES OF THE STOMACH AND INTESTINES, ATTENDED WITH APPRECIABLE 

ANATOMICAL LESIONS. 

AKTICLE I. 

GASTRITIS. 

Gastritis, in the sense in which the term was used some ten or twenty 
years since, viz., to express an individual and special inflammatory dis- 
ease of the stomach, of common occurrence and of supposed great severity 
and importance in childhood, is now well known to be a rare affection. 
It is doubtful, indeed, whether it ever forms a special visceral inflamma- 
tion, except in consequence of the direct application to the organ of some 
irritant substance, such as the mineral acids or arsenic, or, as Rilliet and 
Barthez found, in a few instances, certain remedial agents, as tartar 
emetic, kernies mineral, and croton oil. In the form of catarrh, acute or 
chronic, of the mucous membrane, on the other hand, it is doubtless one 
of the most common affections of childhood, constituting an important 
element in a great many diseases, and especially in the severe forms of 
indigestion, in simple and inflammatory diarrhoea, in cholera infantum, 
and in man}^ of the wasting diseases of childhood, which result from the 
use of improper artificial diet in infants, and of crude and indigestible 
articles of food in older children. 

TTe had almost abandoned the plan followed in our last edition, of 
devoting a special chapter to this subject, but, on further consideration, 
think it will be best to treat of it separately, since, as stated above, cases 
do occur in practice in which the stomach is the chief, if not the only 
seat of disease, and which can be properly designated and described only 
under the title of gastritis. 

Causes. — It has already been stated that the most violent and typi- 
cal cases of gastritis, as a distinct disease, are the result of the applica- 
tion to the organ of some special irritant, as the mineral acids, arsenic, 
boiling water, or of certain remedial agents, and particularly of tartar 
emetic, kernies mineral, or croton oil. These latter agents, the drugs 
just mentioned, cannot produce this effect unless used in large doses, or 
when continued for too long a time. The quantities of the antimonial 
preparations formerly administered, were always thought by us to be 
dangerously large, and we were not at all surprised to find that MM. Ril- 
liet and Barthez, from their experience in former 3-ears in the Children's 
Hospital in Paris, cited them as one of the causes of acute gastritis. In 
the Journal fur KLnderkrankheiten, for the years 1859, 1860, and 1861, 
in the third, fourth, and fifth annual reports of the Public Institute for 
Children's Diseases, of Yienna, 03- the Director, Dr. Luzsinsky, may be 
found in the third report three cases, in the fourth three cases, and in 



ANATOMICAL APPEARANCES. 337 

the fifth two cases of gastritis caused by the accidental drinking of con- 
centrated lye. 

The milder forms of gastritis are vastly more common than the ones 
above referred to. The} T are generally associated with disturbances of 
the intestinal tube also, and constitute by far the majority of the cases 
which come under the observation of the physician. They are caused 
very generally by improper alimentation ; by the same causes, indeed, as 
those which determine indigestion. In infants, an unhealthy state of the 
mother's or wet-nurse's milk, the use of too rich a preparation of cow's 
milk, milk obtained from an unhealthy cow, or a food composed of too 
large a proportion of farinaceous material, are the most common causes. 
In older children, an unwholesome meal, as a surfeit of cakes and can- 
dies, tough meats, unripe, or an excess of ripe fruits, the swallowing of a 
quantity of skins of grapes, of orange peel, of the seeds of oranges, or such 
like imprudences or accidents, of all which we have seen examples, will 
sometimes occasion sj^mptoms which we can refer only to acute catarrh 
of the stomach. In such cases the child may escape any serious conse- 
quences if it rejects, by vomiting, the improper food, soon after it has 
been taken. Or it maj 7 have an attack of cholera infantum or cholera mor- 
bus, and either recover its usual health in a short time, or pass through 
a longer or shorter illness, as the result of these disorders; or, lastly, the 
unhealthy food may be retained for a longer time than usual in the stom- 
ach, and acting as a local irritant on the gastric mucous membrane, may 
set up a true and more or less severe form of the disease we are con- 
sidering. 

Anatomical Appearances. — Death is so rare a consequence of gastritis 
alone, except in the form produced by the direct application of irritants 
to the organ (and even in such, recovery appears to be the rule, since all 
the eight cases referred to as reported b} 7 Dr. Luzsinsky recovered), that 
it is difficult to present a description of the lesions characteristic of this 
variety of the disease. M. Billard, however (Mai. des Enfants, p. 353), 
gives a case from M. Denis, and one observed by himself. M. Denis 
found the mucous membrane of a deep brown color, of a fetid odor, re- 
duced here and there to a state of putrilage, and everywhere easily 
removed in softened strips. A fluid of the color of lees of wine, was 
found macerating the changed mucous membrane, and this he could 
ascribe only to gangrene from excessive inflammatory action. The case 
observed by Billard occurred in a girl three days old, who was brought 
to the infirruar} 7 with a quantity of blackish blood passed into the napkins, 
and also vomited. The child died on the following day. The mouth and 
oesophagus were health} 7 , but the mucous membrane of the stomach was- 
completel} 7 destroyed, not far from the cardiac orifice, over a space as 
large as a thirty sous piece. The centre of this space was stained with 
blackish blood, and its edges, irregularly fringed, were blackened and 
looked as though they had been burned. Outside of this dark circle, the 
mucous membrane was thickened, of a violet-red color, and easily re- 
duced to a pulp. The whole surface of the organ was lined with semi- 
fluid matters, of a bistre color, mixed with sanguinolent striae, and the 

22 



338 GASTRITIS. 

mucous membrane, beneath these matters, was very thin and discolored, 
especially near the pylorus. The small intestine was stained }^ellow with 
bile, and contained fragments of coagulated blood. The large intestine 
was healthy. The liver was bloodless and pale ; the spleen small and but 
slightly injected. No clue is given as to the cause of this grave lesion. 

The gastric lesions belonging to catarrh of that organ are very often 
met with, as we have already stated, but are almost always associated 
with changes in the intestinal mucous membrane. They are observed in 
severe indigestion, in simple and inflammatory diarrhoea, and in cholera 
infantum. For a full account of the histology of this lesion, we must 
refer the reader to the essay on Gastritis and Acute Gastric Catarrh, 
by Dr. Wilson Fox, in the System of Medicine, edited by Dr. J. Russell 
Rejmolds. We shall, however, quote the shorter description given by 
Dr. Niemeyer (op. cit., vol. i, p. 416), of acute gastric catarrh. He says: 
" We seldom have the opportunity of seeing the remains of acute gastric 
catarrh in post-mortem examinations ; when we do, the gastric mucous 
membrane is found reddened in spots by a fine injection; its tissue is re- 
laxed, and its surface covered with a layer of tough mucus. But more 
frequently, especially among children who die with the S3^mptoms of 
cholera infantum, the autopsy gives negative results, except as to appear- 
ances which will be described hereafter. This does not appear strange 
when we remember that the capillary hyperemias of other mucous mem- 
branes, which we have been able to observe directly during life, leave no 
trace after death, and that a relaxation and partial loss of epithelium, 
which we have regarded as the most probable cause of the extensive 
transudation in cholera infantum, may be very readily overlooked in the 
dead body, and can very rarely be observed with certainty." 

The description of the anatomical appearances in gastritis will not be 
complete without some reference to a lesion which, some ten or twenty 
years since, was thought to be one of great importance in children. This 
lesion, known by the names of softening or gastro-malacia, was supposed 
by some to constitute a distinct pathological entity, and to be the result 
in most cases of inflammatory tissue-chauges determined b}^ many differ- 
ent causes. Even then, however, not a few observers believed that the 
lesion was a post-mortem change, and not the consequence of changes 
caused by disease during life. This latter opinion has continually gained 
ground, until now it is generally believed that, when present in a marked 
degree, it is in fact a cadaveric change. Nieme} T er (op. cit., vol. i, p. 416) 
says that the gastro-malacia or softening of the walls of the stomach, found 
on autopsy in children, is always a post-mortem appearance, and that "if 
a child dies who has had vomiting and purging from abnormal fermenta- 
tion in the stomach, and if there are still fermenting substances left there, 
the fermentation will not be arrested by the gradual cooling of the body. 
When the circulation ceases, the stomach can no longer resist the decom- 
position, which then extends to it also, just as the stomach that has been 
cut out of an animal and filled with milk, softens if left only for a short 
time in a warm place. Hence physicians who consider softening of the 
stomach as a post-mortem appearance, may also predict it with certainty 



SYMPTOMS. 339 

when a child that has died of cholera infantum had eaten milk, or any- 
other easily decomposed substance, shortly before death." 

That a certain degree and kind of softening does, however, attend upon 
catarrhal inflammation of the gastric mucous membrane, as a result of 
faulty nutrition of the tissues during life, is probably quite as true as that 
the extensive white softening of one or more of the coats of the organ, 
not unfrequently met with, is the consequence of a post-mortem change. 
Thus Dr. Wilson Fox (loc. cit., p. 858) asserts, that the softening of the 
mucous membrane which accompanies acute catarrh is totally distinct 
from the post-mortem softenings, which are distinguished by the trans- 
parency of the tissues. "It rarely exists," he says, "to any marked de- 
gree, except in extreme cases, but there is always a certain diminution 
of resistance to the finger-nail or to the scalpel, which materially assists, 
when conjoined with opacity and thickening, in distinguishing this con- 
dition. Louis's test of the extent to which it can be torn from the submu- 
cous tissue is a less available one, and applies rather to the states of post- 
mortem solution than to this condition." 

Symptoms. — It is very difficult to give an accurate account of the symp- 
toms of inflammation of the stomach, for the following reasons : they 
have not as yet been studied with a sufficient degree of care ; gastritis is, 
as was stated in the early portion of this article, rarely idiopathic, but 
almost alwaj's a secondary affection in the course of other maladies ; the 
symptoms which betray it resemble so closely those of intestinal diseases, 
as to make it very difficult, if not impossible, to draw a distinction be- 
tween the two ; and lastly, in the great majority of cases, gastric com- 
plaints coexist with intestinal. 

The most important symptoms are vomiting, diarrhoea, loss of appetite, 
thirst, epigastric tenderness, sometimes tension of the abdomen, and 
slight febrile reaction. 

Vomiting is the most important of the different symptoms of gastritis. 
It is not, however, acccording to MM. Rilliet and Barthez, invariably 
present. It was observed by them particularly in cases following the ad- 
ministration of active remedies, while in those which occurred sponta- 
neously, it was much less common. It shows itself especially after the 
taking of food or drink. Sometimes when the stomach is empty, there is 
simply nausea and retching. In severe cases the vomiting is frequent, 
and accompanied by violent straining and pain. Diarrhoea exists in most 
cases, whether the attack be one of simple gastritis, or accompanied with 
enteritis. The appetite is generally lost or greatly diminished. Thirst 
is commonly acute, and often intense. The tongue is described by some 
writers as being generally red, and sometimes smooth and glazed. The 
authors above quoted, state, on the contrary, that it presents nothing 
peculiar in most cases. It was generally moist, only slightly colored, 
covered with a white or yellow coat of variable thickness, and in some 
rare instances, red on the edges and tip, or gluey, or even dry and harsh. 
As a general rule, the abdomen is normal, according to the same authors, 
though in some cases there is more or less swelling and tension. Accord- 
ing to most writers there is generally tenderness on pressure in the epi- 



340 GASTRITIS. 

gastrium. Infants and young children are commonly restless and uneasy, 
as though in more or less pain, while those who are older complain of 
burning in the region of the stomach. It is well to remark that MM. 
Rilliet and Barthez state that tenderness on pressure often exists, not at 
the epigastrium, but in one of the iliac fossse, or at the umbilicus, even 
when the stomach alone is inflamed. The condition of the circulation, 
and indeed all the symptoms, depend so much upon the nature of the 
concomitant malady, that it is difficult to ascertain what are their real 
characters in simple gastritis. Most writers agree that fever usually ac- 
companies the disease, and that it is commonly of the remittent type. It 
is certain, however, from other observations, that it is not alwa} T s present. 

In very violent cases there are added to the symptoms just described, 
those indicative of an adynamic state of the nervous system : prostration, 
cool or cold skin, with perspiration ; weak, rapid pulse ; singultus ; some- 
times convulsions, and death. The symptoms which have just been de- 
tailed as indicating the presence of gastritis, do not generally exist alone. 
They are much more frequently than not associated with other symptoms, 
which show the presence of intestinal disease in the form either of simple 
or inflammatory diarrhoea. That they do sometimes, however, exist alone, 
and that, too, independently of the action of irritating drugs, or of cor- 
rosive poisons, we cannot ourselves doubt, since Ave have several times 
seen them follow attacks of simple indigestion. In such cases, we have 
met with all the symptoms usually supposed to indicate an inflamed state 
of the gastric mucous membrane, — repeated and obstinate vomiting, epi- 
gastric tenderness, entire loss of appetite, and more or less acute fever. 
We have, to be sure, never seen a post-mortem examination of such a 
case, for we have never yet known one to prove fatal. Whether we call 
such an attack gastritis, acute catarrh of the stomach, or embarras gas- 
trique, matters not much. It is the condition which has long been looked 
upon as indicating an inflammatory state of the gastric mucous membrane, 
and until we have more positive evidence than has yet been adduced, 
that inflammation has nothing to do with it, we shall deem it best to re- 
tain the old title. 

Diagnosis and Prognosis.— The diagnosis must rest chiefly on the 
existence and frequency of vomiting, on the presence of epigastric pain 
or tenderness, of swelling and tension of the abdomen and excessive 
thirst, and on the absence of other disease which might account for the 
illness of the child. 

The prognosis will depend on the severity of the gastric and constitu- 
tional s3 T mptoms, and on that of the concomitant disease, when the at- 
tack is secondaiy. When there is incessant and obstinate vomiting, so 
that not even water in small quantities can be retained after several hours 
of sickness, when the tongue is red and glazed, or dry and brown, and 
when adynamic symptoms make their appearance, and emaciation makes 
rapid progress, it is much to be feared that extensive organic change has 
taken place, and that the case will prove fatal. 

Treatment. — The two most important points in the treatment are the 
withdrawal of the causes that may have produced, or may tend to keep 



TREATMENT. 341 

up the disease, if these can be detected, and strict attention to diet. 
Whenever, therefore, the sj'mptonis have made their appearance after the 
exhibition of powerful drugs, as tartar emetic, kermes mineral, or cathar- 
tics, their use ought to be instantly suspended. The child should be put 
on the strictest diet. If at the breast, it must be allowed to nurse only at 
rare intervals, and to take but little at a time. If fed on artificial diet, 
it should be restricted to barley or arrowroot water, to very weak milk 
and water, or to small quantities of milk diluted with lime-water, in the 
proportion of a third or a half of the latter. This is one of Dr. Cham- 
bers's favorite prescriptions, and is an admirable one. Nothing solid and 
no rich liquid nourishment ought to be allowed, unless the child is in a 
state of weakness and debility from previous or concomitant disease, such 
as to make it absolutely necessary to endeavor to maintain its strength. 
Billard even recommends that the child be sustained by means of nutri- 
tive enemata, consisting of farinaceous substances, while the digestive 
function is allowed a total rest. 

Antiphlogistics are useful and proper when the disease occurs in a 
strong and healthy child, when it is associated with fever, and when there 
is nothing in the nature of the accompanying disease, if it be a secondary 
case, to prevent their employment. The most suitable mode of depletion 
is hy leeches, which should be applied to the epigastrium. It is best to 
take but a very moderate quantity of blood, for fear of exhausting the 
patient. After the use of the antiphlogistic remedy, a warm bath will be 
found of great service in moderating the heat of the skin and rendering 
the child more comfortable. Small pieces of ice ought to be put into the 
mouth occasionally as a refrigerant, or small quantities of iced drinks 
may be allowed from time to time. As soon as the bleeding from the 
leech-bites, if leeches have been emploj^ed, has ceased, a warm light mush 
poultice to the epigastrium is a valuable and useful remedy. Some writers 
recommend the use of blisters to the epigastrium. We should much prefer 
a warm poultice or the occasional application of a mustard poultice. 
Opiates are useful in allaying nausea and vomiting, and appear to exert a 
favorable influence on the progress of the disease. 

When vomiting is frequent and troublesome, it may generally be allayed 
by the administration of lime-water and milk, given in teaspoonful quan- 
tities every fifteen minutes or half hour ; by observing the precaution of 
allowing the food and drink to be given only in the smallest quantities 
(from a teaspoonful to a tablespoonful) and at considerable intervals ; by 
the application of warm cataplasms over the abdomen, or a spice-plaster to 
the epigastrium; or, lastly, by the exhibition of a few drops of laudanum 
or paregoric, to be repeated if necessary. If the child becomes weak and 
exhausted, with coolness and abundant moisture upon the limbs, we must 
resort to the administration of some kind of stimulant. The best is weak 
brandy and water, given in very small quantities ; or we may employ 
wine-whey, or milk punch, or the aromatic spirit of hartshorn. 



342 ENTERO-COLITIS. 

AETICLE II. 

ENTERO-COLITIS OR INFLAMMATORY DIARRHOEA. 

Definition ; Frequency. — By entero-colitis or inflammatory diarrhoea, 
we mean that form of diarrhoea which presents, during life, in febrile reac- 
tion at some period of its course, in marked constitutional disturbances, 
and in the mucous, muco-purulent, or muco-sanguineous stools, the proofs 
of inflammatory changes in the intestinal mucous membrane ; and which 
exhibits, after death, the tissue-changes in the small and large intestines, 
which are regarded as the products of inflammation of those organs. 

The disease is one of the most common and one of the most fatal of 
childhood. Few young children die in the foundling hospitals abroad, 
or in the hospitals and almshouses of this country, from insufficient or 
improper food, but die of this affection. Many, a large majorny, we 
think, of the deaths accredited to cholera infantum belong to this dis- 
order. The true choleraic disease is constantly passed through with 
safety, but is followed hy a long, obstinate, exhausting diarrhoea, which 
is in truth an inflammatory diarrhoea occurring as a sequel to cholera. 

A large proportion of the cases of summer diarrhoea are, from the be- 
ginning, cases of this kind ; or they commence as merel}' functional dis- 
turbances of the intestine, and run, sooner or later, into the disorder we 
are now considering. It is one of the most important diseases of young 
children, especially in this country, where our long summer heats, and 
the filthy condition of many parts of some of our most famous cities, 
give it a degree of prevalence and fatality which raise it to the rank 
almost of a pestilence. 

We believe that most of the cases of diarrhoea in children, no matter 
what may have been the exciting cause at the start ; whether a constantly 
improper diet, as in hand-fed children; whether ill-judged experiments 
in new foods by the mother or nurse ; whether the accidental use of un- 
wholesome food ; whether summer heats, exposure to unhealthy and foul 
exhalations, crowding, malarial or epidemic causes, dentition, residence 
in cities, or what not, are prone to end, are nearly certain to end, if they 
become chronic, in this disease. This opinion is the result of the expe- 
rience of one of us in private practice, in this city, during twent} r -eight 
years. It is curious, too, and it is confirmatory of the correctness of this 
opinion, that in our armies during the late war, diarrhoea, whenever it 
became chronic, exhibited lesions which are best indicated by the term 
entero-colitis, if we are to use a name based upon the anatomical lesions 
of the disorder. 

Under the title of entero-colitis or inflammatory diarrhoea, we shall 
then describe the different kinds of diarrhoea treated of by Underwood, 
Eberle, and Dewees, under the titles of bilious, mucous and chronic diar- 
rhoea, and by Dr. John Cheyne (Essays on Diseases of Children, Edin- 
burgh, 1801-2), under that of Atrophia Ablactatorum, or Weaning-brash. 
Entero-colitis is one of the most frequent of children's diseases, though 



FREQUENCY — CAUSES. 343 

it is impossible to determine accurately the mortality it occasions in this 
city, from the returns as at present made by our physicians. 

Thus during the past seven } T ears (1862-1868 inclusive) there were 
7273 deaths under five years of age in this city, from the three diseases, 
cholera infantum, diarrhoea, and dysentery (not to include a comparatively 
small number returned as due to colic, marasmus, inflammation of the 
stomach and bowels, aphthae, &c). Of these, as will be seen bj r inspec- 
tion of the accompanjung table 1 (see p. 344), by far the greater propor- 
tion, namely 5963, are recorded as due to cholera infantum. Our extended 
opportunities of observing the diseases of children in this chVy have, how- 
ever, led us to the conviction already expressed in the remarks which pre- 
face this article, that the great majority of these cases should in reality 
be entitled entero-colitis, while the true choleraic disease, to which alone 
the term cholera infantum should be restricted, is a comparatively infre- 
quent affection. 

We may appreciate yet more accurately the importance and frequency 
of the disease, b} T reference to the statements of MM. Eilliet and Bar- 
thez, who say (lere edit., t. i, p. 483), that, taking into consideration all 
the cases they observed, including tubercular cases, they find that of every 
two children that die, one presents a more or less serious lesion of the 
large intestine. They add : " If it be recollected that this holds true 
particularly in regard to younger children, it will be seen that it is rare 
for a child to die between two and five years of age, without having either 
colitis or softening of the large intestine." Bouchut states that entero- 
colitis is one of the most dangerous affections of children at the breast : 
" It is the most common of all those incident to that age" (p. 210). 

\Te shall describe two forms of the disease, the acute and chronic. 
The acute form is accompanied by active and inflammatory symptoms 
from the first, and runs its course in a few days or weeks ; the chronic 
form is unaccompanied by acute symptoms, and lasts several weeks or 
months. 

Causes. — The two most important causes of this disease amongst us? 
are improper alimentation and the heats of summer. The improper alimen- 
tation consists in an unhealtlry state of the nurse's milk, or, what is much 
more common, of some improper kind of artificial nutriment ; of the latter, 
the kind of food most apt to produce the effect, is one composed exclu- 
sively or in considerable proportion of some of the feculent substances, 
which constitute so large a portion of the diet of children throughout the 
civilized world. To prove the truth of this assertion it is only necessary to 
quote the opinions of those who have most carefully studied the subject. 
M. Talleix (Guide du Med. Prat, t. iv, p. 60, 61, and Bulletin Gen. de 
Therap., article Acute Enteritis of Adults and New-born Children, March, 
1845), clearly asserts that the most frequent cause of muguet, which he 
believes to be essentially connected with enteritis, is a too exclusively 

1 AVe are indebted to the courtesy of Mr. Chambers, the clerk of the Board of 
Health in this city, for the opportunity of collating portions of this table from the 
monthly returns of mortality calculated by him. 



344 



ENTERO-COLITIS. 



Table, showing the Monthly Mortality for the last Seven Years from 
Years of Life ; compared with the Total Monthly Mortality 



Monte. 


1862. 


1863. 


1864. 


1865. 


Mortality. 


6 

a 

a 


Mortality. 


6 

3 

S 

a> 


Mortality. 


if 

a 

0) 


Mortality. 


as 

3 

a 


Cholera 
Infant. 
Dysent. 
Diarrh. 


Total. 


Cholera 
Infant. 
Dysent. 
Diarrh. 


Total. 


Cholera 
Infant. 
Dysent. 
Diarrh. 


Total. 


Cholera 
Infant. 
Dysent. 
Diarrh. 


Total. 


Jan., 


1 

2 

4 


1314 


32.46° 



3 
3 


1061 


38.25° 


1 


5 


1302 


33 28° 


1 
6 
3 


1373 


26.78° 


Feb., 


1 
3 
1 


1080 


32.70° 


5 
3 
2 


1122 
1172 


35° 



3 



1434 


35.97° 


2 
2 

1 


1550 


32.59° 


March, 


2 
2 
3 


1204 


40 25° 



2 

7 


37.26° 


4 
1 
5 


1894 


40.5° 


3 
1 
2 


1868 


47.94° 


April, 


3 
1 
4 


1213 


50 61° 


2 
5 
6 


1488 


49.80° 


2 

2 
6 


1377 


50.58° 


5 
3 
4 


1411 


56.46° 


May, 


9 
4 
5 


1343 


63.70° 


5 
1 
6 


1060 


64.63° 


10 

5 

8 


1529 
1245 


67.20° 


10 
6 

7 


1227 


63.39° 


June, 


20 
3 

8 


1002 


69.14° 


14 

2 
5 


961 


68.67° 


74 

11 
14 


72° 


184 
10 
20 


1690 


76.73° 


July, 


300 
21 
31 


1767 


75.23° 


313 
17 

38 


1859 


77.07° 


259 
24 
32 


1643 


76.08° 


364 
52 
41 


1838 


77.82° 


Aug., 


217 
19 
22 


1755 
1037 


76.70° 


464 
25 

28 


2044 


79.46° 


250 
27 
31 


1956 


79.40° 


245 
42 
23 


1759 


74.74° 


Sept., 


60 
4 
9 


69.36° 


105 

15 

9 


1453 


64.73° 


28 
16 
10 


1251 


65° 


44 
14 

7 


1040 


72.68° 


Oct., 


15 

5 
4 


1235 


58.32° 


14 
4 
5 


1104 


56.08° 


9 
8 
4 


1144 


54.75° 


15 

12 

5 


1084 


54.88° 


Nov., 




2 
5 


1021 


45.20° 


5 

1 


1061 


47.72° 


2 
2 
1 


1212 


45.80° 


9 
8 
3 


1285 


45.35° 


Dec, 




1 
2 


1124 


36.06° 


3 
2 

1 


1404 


35.41° 


2 
2 
4 


1595 


36.77° 



2 
3 


1044 


37.39° 


Total, 


803 






1120 






862 






1139 







FREQUENCY — INFLUENCE OF SEASON AND TEMPERATURE. 345 



Cholera Infantum, Dysentery, and Diarrhoea, during the First Five 
from all Causes, and the Mean Monthly Temperature. 



18(36. 


1867. 


1868. 


Mean Mortality for Seven Years 
from Cholera Infantum, Dys- 
entery, and Diarrhoea. 


gx 

p- a 

O 5 
E-132 


a 

<B 

OQ 
hi 

<2 
« 
3 p 

"S » 

8* 

a 

V 

H 

d 

» 


Mortality. 


o 
t-t 

3 

s 

E-i 


Mortality. 


3 

s 


Mortality. 


2 

3 

S a. 
S 
s> 


Cholera ' 
Infant. 1 
Dysent. Total. 
Diarrh. 


Cholera 
Infant. 
Dysent. 
Diarrh. 


Total. 


Cholera 
Infant. 
Dysent. 
Diarrh. 


Total. 




1 1402 
4 


29.31° 


3 

4 


1376 


25.89° 


2 
2 
1 


1249 


30.12° 


71 
3f 


1296* 


30.87° 


1 
2 



1156 


34.14° 


3 
2 
3 


1042 


40.21° 







1063 


26.65° 


it 


1206* 


33.89° 


3 

3 


1082 


40.85° 


3 

1 
2 


1094 


38° 


1 

1 
1 


1096 


41.12° 


2* 

1* 

4 


1344* 


40.85° 


6 
3 
4 


1034 : 56.06° 


1 
2 



1088 


54.13° 


9 
5 
2 


1357 


48.24° 


4 
3 
H 


1281* 


52.27° 


8 
1 
4 


1304 61.37° 

i 


7 
2 
3 


1260 


59.44° 


4 

1 
6 

71 
8 

7 


917 
1201 


59.66° 
71.99° 


% 


1234* 


62.77° 


68 

2 

10 


1168 


73.04° 


38 
6 
5 


980 


72.19° 


67 
6 
9* 


1178* 


71.97° 


427 
21 
34 


2047 


80.37° 


423 
23 
31 


1795 


76.48° 


423 
14 
32 


1900 


80.94° 


358* 
24 f 
34i 


1837 


77.71° 


366 
36 
41 


2401 


72.5° 


265 
26 
25 


1294 


75.10° 


327 
19 
34 


1570 


78.42° 


304* 
27* 
291 


1825* 


76.62° 


89 
15 
13 


1362 


69.42° 


88 

13 

9 


1012 


68.21° 


128 
14 
24 


1353 


68.80° 


77* 
13 

11* 


1215* 


68.31° 


55 

3 

15 


1828 


58.35° 


24 



10 


1177 


57.65° 


20 

2 
3 


955 


54.08° 


152 
4* 
6f 


1218* 


56.3° 


6 

4 


1037 


48° 


6 

2 
5 


871 


47.79° 


3 

2 



878 


46.91° 


31 

92 

2* 


1052* 


46.68° 


2 
2 
3 


982 


33.63° 


1 
2 

2 


974 


31.78° 


1 

3 


1154 


32.16° 


9 

14 

2$ 


1191 


34.7° 


1252 






1040 






1057 













346 ENTERO-COLITIS. 

feculent alimentation. In the article last cited, while speaking of the 
great importance of this cause, he says : " What proves that my assertion 
is not hypothetical is, first, that all the deaths from enteritis in children 
that I have seen occurred in those who had been placed upon this kind 
of regimen, and second, that the disease did not occur in any of those 
observed by me in private practice, for whom I had directed an exclu- 
sively milk diet up to four, five, or six months of age." He adds that M. 
Trousseau has arrived at similar opinions, after studying the same dis- 
eases at the Necker Hospital ; and that he, on account of the danger of a 
system of diet disproportioned to the digestive powers, recommends that 
children be confined almost exclusively to the breast until after the first 
dentition is completed. Barrier, speaking of the follicular diacrisis (op. 
cit, t. ii, p. 40), states that the artificial food given to children at the 
period of weaning is a frequent cause of the affection, and that of all the 
different kinds of food habitually employed at that period, feculent sub- 
stances are the most injurious. We have frequently known entero-colitis 
to follow the employment of artificial diet, either alone, at the period of 
weaning, or in children who were partly nursed. Children fed wholly 
on artificial diet from birth, rarely escape, according to our experience, 
attacks of the disease, which in many prove fatal. We have, on several 
occasions,, seen children recover rapidly from such attacks, after suffering 
more or less for weeks, by the suspension of a diet consisting wholly or 
in too large proportion of farinaceous materials, and the substitution of 
one composed of milk and cream, prepared with gelatine, and containing 
a very small quantity of arrowroot, rice, or wheat flour (see article on 
thrush, page 304). It is not merely the quality, but the quantity also of 
artificial food that proves injurious to infants. Over-feeding has always 
been recognized as a fruitful source of bowel complaints in early life. 
Another cause is the preparation of the food in too thick and rich a man- 
ner, thereby overtasking the stomach, intended during the early months 
to receive only the thin milk supplied by nature. The custom, therefore, 
of feeding infants on thick oatmeal gruel, with but little or no milk, on 
what is called cracker victuals (pounded crackers with water and sugar, 
or milk), on thick bread and milk, on preparations of rice of too solid a 
nature, or indeed, on any kind of diet not consisting chiefly of milk, and 
in which feculent substances enter merely as secondary constituents, 
may safely be asserted to be the most frequent cause of the disease under 
consideration. 

An unhealthy character of the milk of the nurse is also known to be a 
cause both of simple diarrhoea and entero-colitis. When the granule cells 
which exist as a physiological element in the colostrum secreted during 
the first few days after childbirth, continue to be present after that period, 
the infant is almost certain to suffer from entero-colitis, and not unfre- 
quently to die, unless weaned or transferred to another nurse. So, also, 
when the milk departs widely from the normal characters which it should 
possess, as described at page 306 ; when the nurse is liable to vivid moral 
emotions of any kind, or when addicted to intemperance ; the child is very 



causes. 347 

apt to suffer either from the disease under consideration, or from simple 
diarrhoea. 

That the heats of summer are a most fruitful cause of this disease, no 
one can doubt who will glance at the table given at pages 344 and 345, 
where the mortality from cholera infantum, clysenteiy, and diarrhoea, 
under five years of age, in this chVv, during the seven years from 1862 
to 1868 inclusive, is given. 

The table shows, at a glance, the number of deaths from these diseases 
enumerated, during the period of life specified, in each month of every 
year, with the mean temperature of each month, and also the total mor- 
tality at all ages and from all causes in each year. The reader must not 
forget what we have already stated, that there is every reason to suppose 
that a large majority of the cases reported under the head of cholera in- 
fantum are, in fact, cases of entero-colitis, — at least what we have pro- 
posed to call entero-colitis, as opposed to the less frequent choleraic dis- 
ease to which we restrict the term cholera infantum. It will be seen, in 
this table, that the two months of July and August furnish by far the 
largest proportion of deaths. In these two months, when the mean tem- 
perature is noted between 10° and 80° Fahr., the deaths from this disease 
run up to three and four hundred and upwards ; whilst in June and Sep- 
tember, when the temperature ranges between 60° and 10°, the deaths 
average between 60 and 80, and rarely rise over 100 ; and in January and 
December, with a temperature of from 30° to 40°, they number from 
between three and five to ten and fifteen. The effect of season is here so 
striking that it must interest all, and can leave no doubt, we think, in the 
mind of the reader, but that the elevated temperature of summer is the 
main cause, in this city, of the fatal intestinal disease we are considering. 
Whether heat alone may act upon the system of the child to produce this 
result, or whether it acts always by determining noxious gaseous products 
from the decomposition of animal and vegetable substances thrown into 
our streets, has not yet been demonstrated. From the well-known fact, 
however, that those children suffer most who reside in the more filthy and 
crowded part of the city, whilst the disease is very much less common in 
the open country, and in the cleaner and better ventilated parts of the 
city, we may safely conclude that it is not heat alone that usually causes 
the disease, but that the emanations arising from garbage of various 
kinds, and the imperfect ventilation of houses built in narrow and crowded 
streets, have much to do in its causation. 

We referred, in the general remarks at the beginning of this chapter, 
to the resemblance of the chronic diarrhoea of our armies during the late 
great war, in its mode of causation, symptoms, anatomical lesions, and 
the effects of treatment, to the chronic form of entero-colitis in child- 
hood. 

Any one who will refer to the work of Dr. Woodward, already quoted ; 
or to the essay on Camp Diarrhoea and Dysentery, by Dr. S. B. Hunt, 
in the United States Sanitary Commission Contributions relating to the 
Causation and Prevention of Disease, and to Camp Diseases, &M. (New 
York, 1867) ; or to the Investigations upon the Diseases of the Federal 



348 ENTERO-COLITIS. 

Prisoners confined in Camp Sumpter, Andersonville, &c, by Joseph 
Jones, M.D., published in the volume just alluded to ; will find ample 
proof that improper diet, with heat, overcrowding, and want of cleanli- 
ness will give rise to chronic diarrhoea, the essential lesions of which are 
to be found in radical blood-changes, perverted nutrition, and a localiza- 
tion on the alimentary canal in the form of entero-colitis, very much like 
the disorder we are describing. Dr. Woodward says, in fact, in speaking 
of the nature of the affection (chronic diarrhoea), at page 251 : " From 
the account given above of the pathological anatomy of the disease, there 
can be little doubt that this affection is to be regarded as consisting essen- 
tially of a chronic inflammatory process, involving primarily the mucous 
membrane of the ileum and colon. It may, in fact, be described simply 
as a chronic ileo-colitis, with a tendency to ulceration." Dr. Hunt (Joe. 
cit., p. 294) says : " The essential fact in the pathology of all these various 
forms of flux is the same, and autopsies reveal no distinction between 
cases of diarrhoea and dysentery. They are alike an inflammation of the 
colon or of the small intestine, or of both, attended by ulceration of the 
mucous membrane. The solitary follicles of the colon are seen to be 
enlarged simply, or ruptured, with punched-out ulcerations following. 
The intestinal wall is thickened and changed in color to a red, brown, 
black, or greenish hue." 

It may seem, at first view, visionary and wild to compare the chronic 
entero-colitis or inflammatory diarrhoea of childhood to the same disorder 
in armies and camps ; and j^et we think there is a most striking analogy 
between the two as to causation, symptoms, anatomical lesions, pathology, 
and the results of treatment. The main causes are the same : improper 
diet ; elevated temperatures, the high temperature of the summer season 
in children, and of the Southern States in the armies ; overcrowding, with 
foul air in camps and cities : the sj-mptoms are very much alike, a most 
obstinate diarrhoea, with great constitutional suffering and emaciation ; 
the same lesions are present, only less advanced and extensive in most 
cases of children; and very much the same results follow treatment: 
as in both diet is found to be more important than drugs, and removal 
North in the armies, and in children removal from crowded cities or low 
hot regions of the country to more elevated and cooler tracts are found 
necessary. In children, as in armies, if, at the beginning of the attack, 
the patient is removed from the causes which have produced a simple 
diarrhoea or a cholera infantum, the case is likely to go no further; but, 
if the same causes are continued in operation, the simple diarrhoea passes 
gradually into the chronic inflammatoiy form of entero-colitis, and at 
last the patient recovers only when he is removed to a more favorable 
locality, when the diet is changed to a more healtlry one, or, in the child, 
when he drags through a long hot summer, and the cooler weather of Oc- 
tober or November, and a diminution of the exhalations caused by the 
summer heats in cities, bring at least, in the course of nature, the change 
which was essential to his recoveiy. 

After the causes just enumerated, the one which appears to exert the 
strongest influence is dentition. That the evolution of the teeth, though 



CAUSES — MORBID ANATOMY. 349 

a physiological process, is a powerful predisposing cause of diarrhoea and 
enteritis, cannot be doubted at the present time. It is one recognized 
by many of the most able writers and observers of the day, and by most 
practitioners. MM. Eilliet and Barthez agree with Trousseau in the 
opinion that the simple diarrhoea so apt to occur in children at the epoch 
of the first dentition, is often the origin of chronic intestinal lesions which 
finally reduce them to extreme debility and emaciation. They say that 
careful investigation will generally show that nearly all the cases of in- 
flammation and softening date either from the epoch of dentition, from 
the period of weaning, or from the time at which some considerable 
change in the character of the regimen was made. M. Bouchut states 
that of 110 children in whom the first dentition was going on, 26 escaped 
any indisposition, 38 suffered from restlessness, colics, and occasional 
diarrhoea, so mild as to excite no alarm in the parents, whilst 46 had 
abundant diarrhoea. In 19 of the last series it appeared coincidently with 
the fluxion of the gums, occurring at the time of emergence of each tooth, 
and disappearing entirely in the intervals; in the remaining 27, in all of 
which the process of dentition was difficult, the diarrhoea persisted and 
gradually assumed the characters of entero-colitis. M. Legendre and M. 
Barrier (loc. cit.) both agree in ascribing very great effect to the influence 
of dentition in the production of diarrhoea and entero-colitis. The former 
asserts the diseases referred to to be much the most frequent between the 
ages of six or seven months, and two or two and a half years, which in- 
cludes exactly the period occupied in the first dentition, while they are 
only met with exceptionally after three years of age. 

The act of iveaning is very apt to result in the production either of 
simple diarrhoea or entero-colitis, in consequence, no doubt, of the irrita- 
tion set up in the gastro-intestinal surface, by the change of food made 
at the time. The diarrhoea which occurs at this period was formerly, and 
is still, not unfrequentbv, called weaning-brash. Dr. Stokes (Cyclop, of 
Med., Art. Enteritis) says of this disease that it "is manifestly an acute 
enteritis, produced by the change of food, and in which nature seeks to 
relieve the inflammation by a supersecretion." 

Entero-colitis is prone to occur as a secondary affection in many of the 
acute diseases of children. It is by far the most common in the course 
of the eruptive fevers, particularly measles, and in that of typhoid fever. 
It is also a frequent complication of the latter stages of pneumonia. 

That children of feeble constitution and lymphatic temperament are 
more disposed to the disease than others, is sufficiently proved by the 
evidence of various observers. Lastly, that the incautious and excessive 
use of perturbing systems of medication, addressed to the digestive tube, 
often occasions diarrhoea and entero-colitis, is fully proved by the re- 
searches of MM. Eilliet and Barthez, and by our own experience. 

Morbid Anatomy. — Seat of Disease. — It has been already stated, 
that the alterations of the large intestine are, as a rule, much more fre- 
quent and serious than those of the small intestine. It appears from the 
researches of MM. Eilliet and Barthez, and Legendre, that enteritis rarely 
exists alone ; whilst colitis by itself, or combined with enteritis, is quite 



350 ENTERO-COLITIS. 

frequent. M. Legendre states that inflammation of the small intestines 
never occurs without corresponding lesions of the large bowel, while in 
28 cases of diarrhoea, he found the large intestine alone diseased in, 9. 
From a table of different intestinal lesions, given by Rilliet and Barthez 
(op. tit., t. i, p. 692), it appears that they have met with 45 cases of 
erythematous, pseudo-membranous, ulcerative or pustular enteritis ; with 
113 of the same forms of colitis; with 90 of follicular enteritis; 64 of 
follicular colitis ; and with 28 of softening of the small, and 35 of soften- 
ing of the large intestine. Dr. J. Lewis Smith (op. cit., p. 361), offers an 
anah'sis of the post-mortem appearances in 82 cases of intestinal inflam- 
mation in children. The upper part of the small intestine, embracing 
the duodenum and jejunum, was found inflamed in 12 cases, while in 51 
cases it was free from inflammation and of a pale color. The ileum was 
inflamed in 49 cases, and the csecal portion, including the ileo-csecal 
valve, was the part in which the inflammation was uniformly most in- 
tense, and to which it was often confined ; in 13 cases there was no 
enteritis whatever, and in 16 there was no inflammation of the ileum, so 
that the ileum was inflamed, in all but 3 cases where enteritis was present. 
On the other hand, in all the cases excepting one, namely, in 81 out of 82 
cases, there were lesions indicating inflammation of the mucous mem- 
brane of the colon. In 39 the inflammation had affected nearly or quite 
the entire extent of this portion of the intestine; in 14 it was confined to 
the descending portion entirely, or almost entirely; in 28 cases, the 
records state that colitis was present, but its exact location was not men- 
tioned. 

We may add, that, in the quite numerous autopsies we have made after 
death from this disease, we have invariably found the large intestine 
involved, the inflammatory lesions being in some cases limited to it, while 
in others they also extended into the small intestines. 

It is, therefore, clearly established, that in the inflammatory diarrhoea 
of children, inflammation of the large is considerabl} T more frequent than 
that of the small intestine, and much more apt to exist alone. The lower 
end of the ileum is the portion of the small intestine which presents the 
most advanced and severe lesions ; while in the large intestine the lesions 
are most marked in the caput coli, sigmoid flexure, and descending colon. 

In our description of tile lesions of entero-colitis, we shall divide them 
into those found in the acute and chronic forms of the disease respec- 
tively ; a division made for the sake of correspondence with the descrip- 
tion of the s3*mptoms, although the lesions found in the two stages differ 
from each other only in extent and degree. 

Thus, in the acute stage, the lesions consist of increased vascularhry, 
thickening and softening of the mucous membrane of the intestine, and 
enlargement of the intestinal follicles ; while in the chronic form there is 
discoloration, thickening, with infiltration and induration of the walls of 
the intestine, and more or less extensive destruction of the mucous mem- 
brane from follicular ulceration. 

In the acute stage, the increased vascularit}' (inflammatory hyperemia) 
ma} T present itself as a uniform, more or less intense redness of the 



MORBID ANATOMY. 351 

mucous membrane; an appearance which may sometimes exist in the 
duodenum, but far more frequently is observed in the lower end of the 
ileum and in the colon. More frequently it takes the form of arborescent 
congestion, occurring in patches surrounding the enlarged follicles. The 
peritoneal surface ma} T also be more or less vascular, and quite frequently 
there are little patches of redness and arborescent vascularity, corre- 
sponding to the bases of the inflamed mucous follicles. 

The thickening of the mucous membrane usually corresponds to the 
degree of vascularity, and when the latter is but slight, may be scarcely 
appreciable ; while in other cases, and especially when associated with 
much enlargement of the mucous follicles and oedema of the submucous 
tissue, the thickening is highly marked. The inflamed portions of the 
mucous membrane are also more or less softened, so that they can be 
detached from the subjacent coats more readily than in health. In some 
instances the softening is so extreme that it is impossible to raise up the 
mucous membrane in strips at all. These lesions are all most frequent 
and marked in the lower part of the ileum, and in the descending part of 
the colon. In addition to these changes in the color, thickness and 
consistence of the mucous membrane, the mucous follicles are promi- 
nently enlarged. In the normal state, the isolated follicles of the mucous 
membrane of the intestine, in young children, appear as minute grayish- 
white bodies, and present a grayish point, the excretory orifice, which is 
only visible with the aid of a lens. In the course of entero-colitis, how- 
ever, the morbid development which they undergo causes them to present 
the following characters. The isolated glands are enlarged, and seem, 
therefore, more numerous than in the healthy condition ; they appear in 
the form of lenticular grains seated in the texture of the mucous mem- 
brane, sometimes projecting from its surface, sometimes not, and in other 
instances appearing to be situated beneath it; the excretory orifices of the 
follicles aue often enlarged and tumid, and easily distinguished under the 
form of a grayish or blackish point in the middle of the gland ; in other 
cases the orifices cannot be distinguished until slight pressure is made 
upon the crj^pts, when a drop of turbid mucus may be seen exuding 
through the open point. The color of the distended follicles is dull white, 
rosy, or yellowish ; they are generally from one-third to two-thirds of a line 
in diameter. Dr. Horner {Amer. Jour. Med. Sci., Feb., 1829) speaks of them, 
in this state of development, as resembling "small grains of white sand 
sprinkled over the mucous membrane, and about the size of a millet-seed." 

The agminated glands or patches of Peyer are found in the same state 
of increased development; they are tumefied, and project above the level 
of the surrounding mucous membrane, and the orifices of the follicles are 
congested, so as to appear as dark points, giving to the patch a dotted, 
punctated appearance, which has been compared to the freshly-shaven chin. 

A little later the enlarged follicles present minute, oval, or round 3 r el- 
lowish spots upon their summits, which soften down and allow the con- 
tents of the follicles to be discharged. The enlarged orifice of the follicle 
will then admit a small probe, and may even measure one-half line in diame- 
ter. It leads into a little cavity, which is the follicular sac. The mucous 



352 ENTERO-COLITIS. 

membrane, which overhangs this cavity like a fringe, is thus undermined 
and partly cut off from its vascular supplv, so that we may find a process 
of ulceration advancing in it until the base of the distended follicle is ex- 
posed, appearing as a small, oval, or round shallow ulcer. 

These various conditions of the follicles may all be seen at the same 
time in a single portion of intestine. The enlarged patches of Pe}~er often 
have the appearance of being ulcerated, but a careful examination will 
generally show that this is not the case. The appearance depends upon 
the enlargement of the orifices of the glands, upon unequal tumefaction 
of the surrounding mucous membrane, and upon the presence, in the 
patch, of small, irregular, grayish points, consisting of pultaceous matter, 
which makes the patch look more uneven and projecting than usual. If, 
however, the pultaceous layer be gently rubbed with a piece of linen, it 
can easily be detached, when the mucous membrane beneath is found red, 
softened, and thickened, but not ulcerated. In comparatively rare cases, 
however, there are superficial erosions of the mucous membrane, covering 
the prominent patch. 

The exact date at which the ulceration of the follicles begins, is as yet 
undetermined, and probably A T aries greatly in different cases. It fre- 
quently happens, however, that death occurs, especially from the super- 
vention of a choleraic condition, whilst they are still merely in a stage of 
enlargement. When, on the other hand, the disease passes into the 
chronic form, the lesions which we have above-described become more 
and more extensive. This is especially the case with the lesions of the 
large intestine, for it is even more true with regard to chronic than acute 
entero-colitis, that the chief seat of the disease is in the colon. 

In chronic entero-colitis, the intestine is often contracted, and the peri- 
toneal surface may present patches of discoloration. The thickening and 
infiltration have now affected the submucous and muscular coats, and have 
been followed by induration of the tissues, so that the walls of the intes- 
tine are often abnormally rigid. This is especially true with regard to the 
lower part of the descending colon and the rectum. The mucous mem- 
brane is seen to be riddled, not with mere superficial erosions, but with 
true ulcers, affecting the whole thickness of the membrane. These ulcers, 
when isolated, are from one to one and a half lines in diameter, oval or 
circular in shape, and either have sharpcut edges, as though the piece of 
mucous membrane had been cut out with a punch, or the mucous mem- 
brane bounding them is undermined. Frequently, however, these ulcers 
coalesce, and at the same time extend in depth, so that large, sinuous, 
irregular ulcers are formed, with thickened, slate-gray, undermined edges, 
and having for their base either the submucous or muscular coats, which 
may be covered with a pultaceous, apparently pseudo-membranous layer, 
of a grayish-white color. These ulcers surround and include irregular 
islets of mucous membrane, which are swollen, infiltrated, vascular, and 
discolored. That the large and deep ulcerations just described, even when 
most extensive, take their start from the mucous follicles, is proved by 
the frequent presence amongst them of other ulcerations of more recent 
date and smaller size, which present all the characters of the follicular 



MORBID ANATOMY. 353 

ulcer, and show clearly the origin of the larger and more advanced ulcer- 
ations. Occasionally there is a marked deposit of pigment in the bases 
of the ulcers, and in some cases small coagula of blood have been found 
adherent to their bases. 

We have already had occasion to allude to the marked analogy be- 
tween the disease under consideration, and the form of camp diarrhoea 
described by Woodward {op. cit.) ; and one of the most powerful argu- 
ments in favor of the essential identity of the two affections, is the per- 
fect correspondence between their anatomical lesions. We present below 
a summary of the microscopical changes in the intestine daring the de- 
velopment of these lesions, as determined by the careful investigations of 
Dr. Woodward {pp. cit., p. 24(3). In the early stage, attended merely with 
thickening and softening of the mucous membrane, microscopic examina- 
tion shows marked multiplication of the connective tissue cells about the 
base of the follicles, and soon the tissue is occupied by great groups of 
small, rounded, or slightly polygonal cells. The delicate layer of muscu- 
lar tissue immediately beneath the base of the follicles, presents, at first, 
enlargement and proliferation of its nuclei, whilst later it often ceases to 
be recognizable, being obscured by the luxuriant cell-growth. In the 
most intense cases, the cell-growth here described as attained toward the 
surface of the membrane, may take place throughout its whole thickness, 
and even involve the subjacent muscular layer. 

A similar proliferation takes place in the connective tissue, which lies 
between the follicles. The epithelial layer, which invests the mucous 
membrane, and is prolonged into the tubular follicles, either is the seat 
of rapid cell multiplication, or is exfoliated and replaced by round gran- 
ular cells from the adjacent connective tissue cells. The epithelial lining, 
near the orifice of the follicles, appears to undergo these changes most 
readily and with the greatest rapidity. 

The closed follicles also present rapid cell multiplication, which affects 
the parenchyma of the follicle, as well as the connective tissue of its cap- 
sule and the surrounding cellular tissue. Microscopic examination then 
shows the follicle distended with small, rounded, granular cells, and im- 
bedded in a luxuriant growth of similar cells, which render it almost or 
quite impossible to draw the line where the follicle terminates and the 
surrounding connective tissue begins. "Ulceration usually appears to 
originate in the rupture of one of the closed follicles, and the discharge 
of its softened contents into the intestinal cavity. This is followed by 
the liquefaction of the intercellular substance, and the consequent libera- 
tion of the broods of minute cells, into which the surrounding connective 
tissue has been transformed. Hence results one of the punched-out ulcers 
described above. In the subsequent extension of the ulceration, by which 
large, irregular, sinuous ulcers are produced, the progress seems to take 
place chiefly in the submucous connective tissue, the superficial part of 
the mucous membrane resisting the process until undermined, and its 
nutritive supply cut off. Hence arises the excavated undermining char- 
acter of the edges of the ulcers. From the anatomical point of view, it 
will therefore be perceived that the morbid process, in the cases in which 

23 



354 ENTERO-COLITIS. 

there is no ulceration, is essentially the same as in those in which ulcer- 
ation is present. The one lesion is only a later stage of the other." 

Not unfrequently there will be found one or more intussusceptions of 
the ileum. These are usually readily restored, and have evidently oc- 
curred during the act of dying. Smith has, however, " in a few instances, 
found intussusceptions which sustained the weight of two feet or more 
of intestine, without being reduced, and which, from being in their inte- 
rior more vascular than the contiguous membrane, had probably occurred 
some hours or days before death, but being sufficiently pervious to allow 
the food to pass, the symptoms of obstruction were lacking." 

The Mesenteric and Mesocolic Glands are nearly always enlarged, the 
most marked enlargement corresponding to the lower end of the ileum 
and the descending colon. The enlarged glands are of a pink color, and 
rather more soft and succulent than normal. 

Stomach. — In the great majority of cases the stomach is quite healthy; 
in a few instances, however, there may be found congestion of the mucous 
membrane, slight enlargement of the mucous follicles, or softening of the 
mucous membrane, probably cadaveric in most cases. 

Liver. — Many authorities, apparently led by the presence of s3 T mptoms 
supposed to indicate disturbance of the function of the liver, have assumed 
that there is in most cases of entero-colitis some morbid condition of this 
organ, but extended observation has disapproved this view. 

Thus Hallowell (Amer. Journ. Med. Sci., Jury, 1847) found, that in 14 
-cases, the liver was affected in but 1 case, when it was enlarged ; and 
Smith (oj). tit., p. 370) has published the result of 32 post-mortem ex- 
aminations in regard to this point, which confirm the same conclusion. 
Thus, he states, "there was no evidence from the post-mortem appear- 
ances of the liver in these cases of any congestion, or torpiclit} r , or hyper- 
activity, or perverted secretion. The size of the liver was in some cases 
veiy different in those of about the same age, but probably there was no 
greater difference than usually obtains among glandular organs within 
the limits of health. In most of the cases the liver was examined micro- 
scopically, and the only fact worthy of note observed was the variable 
amount of fatty matter. Sometimes it was in excess, sometimes in mod- 
erate quantity or rather deficient, and sometimes in greater amount in 
one portion of the organ than in another." 

The thoracic viscera present no constant or important lesion, though 
in a certain proportion of cases, there may be found more or less hypo- 
static bronchitis with collapse of portions of the lungs. 

When death occurs during the acute stage, the brain presents no lesions 
dependent upon the disease. When the case has been protracted and at- 
tended with much wasting of the solids and fluids of the body, the brain 
also diminishes in size, and there is frequently found marked excess of 
subarachnoid effusion in cases where the fontanelles have closed ; while 
if these spaces still remain unossified thej^ become markedly depressed. 
These appearances are, however, purely passive in their character, and 
depend upon the wasting of the brain. 

Pathology. — The pathology of inflammatoiy diarrhoea is involved in 



SYMPTOMS — DURATION. 355 

great obscurity. "We are now pretty well acquainted with the physical 
conditions under which the disorder is most apt to be developed. Early 
age, the period of dentition, high temperatures, improper food, residence 
in cities, and especially the crowded occupation of small and illy venti- 
lated buildings, in narrow courts and alle3 r s, where unhealthy exhalations 
arise from the decomposition of filth and dirt of all kinds, are the chief 
conditions which precede the outbreak of the disease. But how these 
conditions act to produce their effect is still a matter of doubt. To at- 
tempt to reason upon a matter so full of difficulty seems almost useless, 
and yet we shall venture to place before the reader some thoughts we have 
had upon the subject. 

There are two broad generalizations which we think, may be safely as- 
sumed to be true. 1. An unhealthy food, one incompetent to furnish to the 
bodj- what it needs for the purposes of nutrition, as farinaceous food or un- 
healthy milk, is sure to produce the disorder we are considering, no matter 
how favorable ma}* be the circumstances, in all other respects, in which the 
child is placed. 2. The best breast-milk in the world, or the most correct 
artificial diet, will not save a child from this disorder, who is located in an 
ill-ventilated house in a dirty and filthy quarter of a large city during 
hot weather. Here the heat to which the child is exposed, the heavy air 
loaded with foul exhalations which it breathes, determines a condition of 
the health in which the digestive organs can no longer digest properly the 
food offered them. In both cases the same result is produced. In the 
first, the stomach cannot change the originally improper character of the 
food into healtlrv material. In the second, the diseased and enfeebled 
organ loses the power to digest even proper food. In both the ali- 
mentary canal is filled with the products of an improperly digested food. 
Whether these unhealtlrv products in the alimentary canal act chiefly as 
local irritants to the mucous membrane, and thus determine the tissue- 
changes met with ; or whether, as Rilliet and Barthez suppose, some mor- 
bid condition of the blood is brought about, which of itself gives rise to 
the changes in the mucous membrane through a morbid action of the dis- 
eased blood on the nervous system, and particularly on the sympathetic 
nerves, we cannot say. Most probably they act in both ways, and the 
resultant effects are the consequence of the two trains of diseased action 
set up, the local and the general. 

In either case a constitutional condition is brought about, the essen- 
tial feature of which is a slow innutrition or inanition. It is altogether 
probable, moreover, that a condition partaking of the scorbutic, must he 
induced, so that we have, after the disorder has lasted for several days 
or weeks, the general debility of a slow inanition, and blood-alterations 
which resemble those of scurvy. 

Symptoms ; Duration. — In infants the acute form of entero-colitis 
generally begins with restlessness and fretfulness. The mother observes 
that the child sleeps less than usual and for shorter periods, and that its 
sleep is uneasy and broken by sighing or moaning, or by occasional ex- 
pressions of pain flitting across the face. It takes the breast less fre- 
quently, and is satisfied to nurse for a shorter time, showing thereby an 



356 EXTERO -COLITIS. 

evident diminution of appetite. At the same time it is apt to reject its 
milk in larger quantities than usual, and this is often observed to have 
a very acid smell. After these symptoms have lasted a few days, and 
sometimes without them, the peculiar sjunptoms of the disease, the diar- 
rhoea and other abdominal sjunptoms, make their appearance, and are ac- 
companied by febrile reaction in most cases. 

In older children the acute form may come on suddenly, with diarrhoea, 
loss of appetite, thirst, sometimes vomiting, abdominal pain and fever, 
from the first ; or, as happens very frequently, the case begins with slight 
diarrhoea, unaccompanied hy fever, or other signs of sickness, and it is 
not until after several, or eight, ten, or even more days, that signs of in- 
flammation make their appearance. 

After the disease is established, the most important sj^mptoms are the 
following. The diarrhoea, which is the most prominent and characteris- 
tic, presents various characters. In order to appreciate this symptom as 
its importance requires, the practitioner ought alwa^ys to see the napkins 
of the child at least once, and often more frequently, in the clay. It exists 
in almost all cases of entero-colitis, in the erythematous and follicular 
inflammations, and in the ulcerations and softening which accompany or 
succeed simple inflammation. It is seldom absent, and 3^et that it is so 
sometimes, is proved by the facts mentioned by MM. Rilliet and Bar- 
thez, who state that they have calculated, from their cases, that it is 
wanting in about one of every twelve cases of inflammation or softening 
of the intestine. They add. however, that it is absent only in slight at- 
tacks, and is always present when the disease is severe. It varies greatly 
as to the frequency, abundance, and character of the stools. It varies 
also in its mode of progress, so that it presents great differences as to all 
these points from day to day, and at different portions of the same clay. 
We may remark in general, however, that in proportion to the severity 
of the inflammation, so is the diarrhoea violeut and constant, and that it 
usually increases as the signs of inflammation become more and more 
marked. It is rare to have severe diarrhoea when the anatomical lesion 
is of slight extent, though this does sometimes happen. The number of 
the stools, as has been stated, is exceedingly variable. This depends in 
great measure upon the violence of the case ; for, while in those which 
present the symptoms of an inflammation of small extent, the stools sel- 
dom amount to more than six or eight a day, in those in which the evi- 
dences of more extensive and severer inflammation are present, there 
will be fifteen, twenty, twenty-five, or even more per cliem. The consist- 
ence of the stools may vary between that which characterizes them in a 
state of health, and that of the thinnest serous fluid. The materials of 
which the} 7- are composed consist chiefly of mucus, bile, serum, small 
portions of feculent matter, portions of undigested caseine or other food, 
and blood. M. Bouchut (loc. c?Y., p. 219) describes those of very young 
children as presenting the following characters. 

1. They are semifluid, homogeneous, greenish, and similar to cooked 
vegetables ; neutral. 

2. Semifluid, homogeneous and green ; often acid. 



SYMPTOMS — DURATION. 357 

3. Semifluid, heterogeneous, greenish, and mixed with yellowish frag- 
ments of ordinary faeces ; neutral. 

4. Semifluid, heterogeneous, greenish, and mixed with fragments of 
undigested caseine ; acid. 

5. Diffluent, greenish, heterogeneous, composed of a large quanthry of 
water in which float yellowish and greenish or whitish particles ; acid. 

6. Diffluent, greenish, like the preceding, and mixed with gas of a 
mawkish and sometimes sourish smell. 

7. Diffluent, completely serous. 

8. Bloocty stools are very rare at this age. We have met with them 
once only in a child affected with acute hepatitis. 

Such are the appearances of the stools in children who have not com- 
pleted the first dentition. After the epoch of the first dentition the dis- 
ease becomes much more rare, and when it occurs, is generally of a milder 
character, so that the discharges differ less from their healthy characters. 
Tnder these circumstances, they are usually less frequent, not often ex- 
ceeding six, eight, or ten in the day, and retaining generally their yellow 
color or becoming brownish ; they are commonly of a semifluid consist- 
ence, and may be called bilious. When, on the contrary, more frequent, 
they become fluid, abundant, mixed with mucus, and are either of a light 
yellow or brownish, or more rarely, of a greenish color. In some cases 
there are, in addition to the substances mentioned, pus, which indicates 
ulceration of the lower portion of the intestine, and fragments of false 
membrane. Moreover, it is very common in older children to observe 
traces of blood in the stools, sometimes in considerable quantities. We 
may remark that we have several times met with stools containing blood 
in children within the 3*ear, but much less frequently than after that age. 
The presence of blood generally coincides with small and frequent stools, 
attended with much straining, and often severe pain, and almost always 
indicates follicular inflammation and ulceration of the large intestine. 

The serous fluid alluded to sometimes constitutes the whole of the dis- 
charge, so that the napkins are merely wetted through, without- any or 
but a very small quantity of solid matter being left upon them. This 
kind of stool is very frequent in the cholera infantum of this country. 
The odor of the stools is important. In the beginning, while the dis- 
charges still retain some of their natural characters as to color and con- 
sistence, it is often very offensive, but as the case goes on, and the greenish 
color predominates, it is either sour, or becomes very slight. In some 
violent cases, in which the discharge consists of a watery, dark-brown 
fluid, the odor is fetid. 

After diarrhoea, the most important symptoms are those which concern 
the form, size, and tension of the abdomen, and the presence or absence 
of pain or tenderness on pressure. In infants the abdomen is more dis- 
tended than usual; but, according to Bouchut, the tension depends on 
the muscular effort made by the child to resist the hand of the physician. 
He says that when it is carefully examined, while the attention of the 
child is attracted in some other direction, it is found to be soft and 
supple, and rarely painful to the touch. In older children it is, in many 



358 ENTERO-COLITIS. 

acute cases, but not in all, enlarged, sometimes tense and sonorous, and 
very generally painful to the touch. The seat of pain is variable, but 
generally it is in one of the iliac fossae or at the umbilicus. It is seldom 
acute, though the child not unfrequently shrinks away and cries out, as 
though it were excessive, from fear of the examination. It is easy to dis- 
tinguish when the pain is real and when apparent, by withdrawing the 
attention of the child, by some device, from the examination, in which 
case it will cease to notice the palpation ; or by touching some other part 
of the body, when, if the crying and shrinking depend on fear or nervous 
excitation, they will be as violent as when the abdomen is touched. Pain 
to the touch is an important s3^mptom, as it is very generally indicative 
of acute enteritis. Gurgling is rare, according to MM. Rilliet and Bar- 
thez, in ordinary entero-colitis, though very generally present in typhoid 
fever. 

Vomiting is very common in young infants, and is generally repeated 
several times a day. In severe and rapid cases it is a very troublesome 
and alarming symptom. In older children it is much less common, and 
is never really violent, except in some of the most acute cases. In them 
it is confined to the first few days of the attack. 

After the diarrhoea is fairly established, young infants are almost al- 
ways either very irritable, peevish, and restless, or weak, languid, and 
subdued. Their slumber is short and disturbed, and generally they sleep 
much less in the twenty-four hours than when in health, unless under the 
influence of anodynes. Older children are generally somewhat restless 
and irritable, but much less so than infants. There is seldom an}^ dis- 
order of the intelligence, though in acute cases there is sometimes slight 
delirium or headache. Fever exists in all acute cases. It is seldom con- 
tinuous in infants except for the first few daj T s, after which it almost al- 
ways assumes the remittent type. It is marked by increased frequency 
of the pulse, which rises to 120 and 140, or in bad cases much higher; by 
heat of skin, often intense during the exacerbations ; by thirst and di- 
minished appetite ; and by dryness and heat of the mouth. In older chil- 
dren the pulse is not generally so high as in infants, and in many of the 
mild cases the fever is very slight or there is none at all. In acute cases, 
however, it is sometimes continuous and marked by rapid pulse and great 
heat of skin. 

The tongue is generally normal, though sometimes red on the edges 
and tip in acute cases. It is seldom dry, except during the fever. The 
appetite is almost alwaj-s lost, and the thirst generally increased, though 
to a less degree than in diseases of the stomach. 

The countenance presents nothing peculiar, except that the features are, 
according to MM. Killiet and Barthez, drawn down towards the inferior 
portion of the face. Emaciation always takes place as the disease pro- 
gresses, and in very severe cases, occurs with the greatest rapidity, so 
that in a very few da} r s the child will be reduced from an appearance of 
vigor and strength, to that of the greatest debility. As this occurs the 
flesh loses its firmness, the skin hangs in folds upon the trunk and limbs 
and is dull and dirty in its tint, the e}^es become sunken and surrounded 



SYMPTOMS — DURATION. 359 

with bluish circles, and the whole appearance of the child is that of misery 
and exhaustion. 

In infants it is very common to meet with erythema of the buttocks 
and thighs, produced by the contact of the acrid stools and urine with 
those parts. This symptom is said by Bouchut to exist in five-sixths of 
the cases. We feel quite sure that it does not exist in so large a propor- 
tion of those which occur in private practice, though we have met with it 
in numerous instances. When severe it is generally accompanied by 
papules, which ulcerate after a time and form superficial ulcerations upon 
the skin. These ulcerations sometimes run together and become of con- 
siderable size and depth. In the form of the disease met with in the 
children's hospitals in Paris, erythema and ulcerations of the heels and 
internal malleoli are also met with, and constitute a serious complication 
in the case. They are said to depend on want of cleanliness, and the 
rubbing together of the feet of the child, unprotected by covering. We 
have never met with them in private practice. 

The duration of the disease is stated by the French writers to be gener- 
ally about fifteen days, at the end of which time convalescence is usu- 
ally established. It may be shorter or longer. According to our own 
experience it is entirely uncertain. Most of the cases that have come 
under our notice have been rather shorter. The disease subsides gradu- 
ally. The number of stools diminishes ; they become less abundant and 
more consistent, and return to their natural color and odor ; the pain on 
pressure, and the enlargement and tension of the abdomen disappear ; 
and as this occurs, the fever subsides, the appetite returns, the temper 
improves, and the child enters into full convalescence. 

The chronic form of entero-colitis generally follows the acute, though 
it sometimes presents many characteristic features from the first. It 
differs from the acute form chiefly in the absence or the much slighter 
degree of fever and other constitutional symptoms in the early stage. 
The diarrhoea is less abundant and less frequent. At first the child re- 
tains its spirits and many of the signs of health. But gradually its 
strength fails, the temper becomes irritable, the complexion grows dark, 
sallow, and unhealthy, the skin becomes dry and harsh, and, in conse- 
quence of the emaciation which takes place progressively with the other 
symptoms, hangs in folds around the shrunken extremities, or is drawn 
tightly over the joints and other osseous protuberances. The tongue is 
generally moist and natural, though in some cases red and dry, whilst in 
others it, together with the lips, partakes of the pallor which pervades 
all parts of the body. The abdomen is usually distended and sonorous 
on percussion, and may be painful or not on pressure in different cases, 
or in the same case at different periods of the disease ; its parietes some- 
times offer no resistance to the touch, so that the intestinal convolutions 
may be readily felt by the hand, or even between the fingers ; and in some 
cases we have seen them so thin and relaxed, though the abdomen was 
more prominent than natural, that the outlines of the intestines, and even 
the peristaltic movement were visible upon the exterior. The appetite 
generally persists in spite of the gravity of the disease, and is sometimes 



360 ENTEROCOLITIS. 

increased. The stools, as has been stated, are not so frequent as in the 
acute form, seldom numbering over six or ten in the clay and night. The}' 
consist of the products of an imperfect digestion, and contain not unfre- 
quently the alimentary substances in the state in which they were swal- 
lowed, mixed with mucus, serum, pus, and sometimes blood. Their con- 
sistence varies constantly, but they are usually semifluid. Their odor is 
seldom natural, and often extremely offensive. 

The course of the disease is very irregular. Even in the worst and 
most prolonged cases intermissions or remissions occur, so that the child 
will often improve greatly for cla} T s or weeks, and then suddenly relapse 
into as bad a condition as ever. In favorable cases these remissions be- 
come more and more frequent, and the S3 T inptoms gradually improve, 
until at length the child is restored to health. In fatal cases death is oc- 
casioned by the utter deterioration of the general health which finally 
occurs, and the child perishes worn out hy long illness, or, as more fre- 
quently happens, some complication arises which hurries on the fatal 
event. Thrush is a frequent complication of chronic entero-colitis, and 
doubtless often hastens the death b}^ the impediment which it occasions 
to the nursing or feeding of the child. Vomiting has almost always oc- 
curred towards the close of the fatal cases that we have seen, especially in 
those in which extensive thrush was present. 

The duration of this form is of course very uncertain. It may last for 
weeks or months. "We have known it to last two and three months in 
several cases, and in two others it lasted with occasional intermissions, 
in one a year, and in the other eighteen months. 

Diagnosis. — The diagnosis of acute entero-colitis is not difficult. There 
is no disease with which it is likely to be confounded. The characteristic 
features of the malady are the diarrhoea and other abdominal symptoms, 
and the absence of signs of other disease. The secondary cases are dis- 
tinguished by the occurrence of the usual symptoms of entero-colitis 
during the progress of the primary malady. 

The chronic form is not likely to be mistaken for any other disorder, 
unless it be the diarrhoea which occurs in tubercular disease, from which 
it is to be distinguished by the presence in the latter of the signs of tuber- 
culosis of other organs. 

Prognosis. — Acute entero-colitis is always a serious disease in infants. 
The prognosis will depend in great measure on the circumstances under 
which the affection has been developed. It is much more unfavorable in 
a child fed on artificial diet, either wholly or in part, than in one who is 
nursed at a fine breast of milk. It is more unfavorable also in weak and 
delicate than in robust and vigorous children, and in those of poor people, 
who live in crowded and unhealthy portions of cities and towns, whose 
habitations are small, damp, and ill-ventilated, and whose food is coarse 
and insufficient, or improper, than in those placed in more fortunate and 
more healthful hygienic conditions. It is a more dangerous, disease in 
summer than in winter. In hospitals for children it is a very fatal dis- 
order, owing to the bad hygienic conditions under which the inmates are 
placed. In children who have passed through the first dentition, the 



PROPHYLACTIC TREATMENT. 361 

prognosis is, as a rule, favorable. The disease is seldom dangerous when 
it occurs as a primary affection, while, as a secondary affection, on the 
contrary, it is much more apt to be serious. 

The unfavorable symptoms are : great frequency of the stools ; collapse ; 
violent vomiting or retching ; and dangerous cerebral symptoms, as coma, 
rigidity of the limbs, paralysis, or convulsions. 

Treatment. — The prophylactic treatment is very important. It in- 
cludes attention to habitation, diet, dress, and exercise. The most fre- 
quent causes of entero-colitis are high summer temperatures, residence in 
an unhealthy locality, and improper diet. A child may have been born 
of the most health}' parents ; may be living, if an infant, on the most 
healthy food in the world, the milk of a perfectly sound woman, or, if it 
have been weaned, on the best possible substitute for breast-milk, one 
selected by the most consummate medical art ; and yet, if it be the un- 
fortunate resident of some low, crowded, and unclean part of any of our 
cities in the summer season, it has but small chance of escaping inflam- 
matory diarrhoea or cholera infantum, to be followed by chronic diarrhoea. 
Or, a child may be living in the best part of these cities, with every ad- 
vantage that wealth and the medical art can give, and, if in the period of 
the first dentition, and the summer heats be great, it will be only too apt 
to have some form of the disease we are considering. Under the latter 
circumstances, its chance of escaping the disease will be vastly greater than 
under the first-named conditions, but the true prophylaxis is, where the 
parents are so situated as to be able to do that which is best for the child, 
removal from the city during the hot season (from the early part of June 
to the last week of September) into some cool and healthy region of coun- 
try. We have long thought that the best region to spend the summer in 
is a somewhat high and cool part of the country, where the breezes have 
full sweep, and where the topography is such that water runs off' rapidly, 
or sinks fast into the soil. The seaside, if it be a point where there are no 
marshes and no malaria, and where the supply of milk and other whole- 
some food is abundant, is an excellent place. We have seen more remark- 
able sudden effects from the removal of a dangerously sick child to the 
seaside, than from a change to the interior ; but, nevertheless, for a con- 
tinued residence of three months, we prefer a high interior locality. 

On the other hand, if a child be placed in the most favorable possible 
condition as to locality, and the diet be a radically bad one, a deficient or 
unhealthy breast, .improper artificial diet, or a foolish allowance on the 
part of the mother or nurse to the child of a variety of vegetables, of 
fruits, and especially of berries like currants or gooseberries (and we have 
known such things), it can scarcely escape the penalty of a fit of illness 
more or less severe. 

A child who is so unfortunate as to get a sharp attack of entero-colitis 
in June or July, is very apt to continue more or less sick during the rest 
of the summer, so that the true proplrylaxis is to take it away from the 
city early in June to avoid this clanger, and not to return until after the 
September heats are over. 

As the reasons for decisive medical action in any disorder cannot be 



362 ENTERO-COLITIS. 

too strongly demonstrated, and as this subject of removal is a very im- 
portant one, we think it well to advert here to the results of experience 
in this matter in the diarrhoea and dysentery of our armies during the 
late war. Here we have the experience of intelligent army medical offi- 
cers in vast numbers of cases, — cases, too, so grouped together as to give 
opportunhVy for the most accurate observation. In the Sanitary Memoirs 
of the War of the Rebellion, collected and published by the United States 
Sanitary Commission (Chapter VII, Camp Diarrhoea and Dysentery, by 
Sanford B. Hunt, M.D., p. 291), will be found a most valuable essay on 
the causes and treatment of diarrhoea and dysentery, which no one can 
read without being impressed with the similarity (saving the ages) of 
those diseases to the one we are describing. At page 304, Dr. Hunt sa} T s: 
"But in others the disease progressed, became follicular, and finally ulcer- 
ative. In the treatment of these, great difficulty was experienced, from 
the fact that the patient was still exposed to the causes of this malady ; 
and it came to be a fixed doctrine at Southern and Southwestern stations 
that confirmed cases had no security for cure except by removal to the 
North. This soon became a governmental policy, and hospitals were es- 
tablished in New England, along the Lakes, and in the Northwest, to 
which chronic cases were sent in great numbers. Among patients not 
thus removed, but treated in Southern hospitals, much vacillation and 
irresolution were exhibited in the prescriptions of surgeons, as happens 
in all diseases, the treatment of which by drugs is usually unsuccessful. 
To trace the history of an individual case was to find that the prescribe!* 
had run the round of all remedies, from opium to astringents, from astrin- 
gents to quinine, from quinine to bismuth, and from bismuth to nux 
vomica, from nux vomica to mercurials, returning almost alwaj^s to opium 
as the drug, which at least alleviated, if it did not cure." 

The dress ought to be suited to the weather. It is best to keep on the 
child, even in hot weather, a very thin and soft flannel shirt, with short 
sleeves. This should never be removed. A 3 r oung infant should wear all 
summer long a thin and light flannel petticoat. A child a year old may 
have the flannel petticoat removed for a few days when the temperature 
rises to above 85° or 90°, when it suffers evidently from the heat ; but so 
soon as the temperature falls to 85° or below, the petticoat should be re- 
placed. This happens only for a few clays in our summer season, and the 
change should be made with great care, and only under the supervision 
of an intelligent and watchful mother or nurse. 

Exposure to the open air is another point in the prophylactic treat- 
ment which is of great importance. In country houses in the summer, a 
young infant may get nearly as much air as it needs, but in cities the air 
of houses is much more dull and stagnant, and the child ought to be car- 
ried out into the streets and squares for several hours morning and eve- 
ning. If possible it should be taken to drive into the open country. 
Short excursions, \)j rail or boat, for the children of the poor, who can- 
not escape from the city in summer, are very useful in carrying the child 
safely through the summer. But in all such jaunts after health, the pa- 
rents should so arrange matters that the child shall be as little fatigued as 



DIETETIC TREATMENT. 363 

possible. The best plan is to go in the morning and return in the even- 
ing, resting through the middle of the day at some point where the child 
can take the rest and midday sleep, which are quite as important as fresh 
air. Included in this subject is that of exercise. This becomes ver}^ im- 
portant when the child is old enough to walk and run, for then an ignor- 
ant or thoughtless woman might think the more exercise the better, 
whereas it is necessary to watch such children very carefully, since, if 
they are allowed or enticed to take undue exercise, the resulting fatigue 
becomes a positive cause of diarrhoea. A child of two or three j^ears old 
should never be induced to take long and continuous walks ; it ought to 
frisk and play, not walk straight ahead, like a man in training; for that 
kind of exercise, we have remarked, never suits children well. 

It has already been stated that one of the most frequent causes of the 
malad}^ is the attempt to bring up the child on artificial diet, and particu- 
larly on one of an improper kind. It is clear, therefore, that to avoid the 
disease it is necessary that the child should, if possible, be nursed. If this 
cannot be done, the diet ought to be wisely selected and regulated in all 
its details b}~ the plrysician. The one most proper is evidently that which 
most closely resembles the natural aliment of the infant. For directions 
as to diet, we must refer the reader to the remarks upon diet at page 297, 
where we have discussed this point quite fully. 

Diet in the Attack. — After the disease has made its appearance, the diet 
should be very carefully regulated. This constitutes, in truth, the most 
important point in the treatment. If the child is nursing, it ought to be 
confined entirely to the breast, and should the nurse have a large quan- 
tity of milk, and the stools exhibit considerable quantities of undigested 
caseine, it must be somewhat restricted as to the frequency and length of 
time it is allowed to nurse ; in other words, it must be moderately dieted 
for two or three days. Should there be the least suspicion that the 
milk of the nurse is unhealthy, it ought to be examined as before di- 
rected, and, if found unhealthy in any respect, a new nurse must be pro- 
vided. If the disease comes on shortly after weaning, and persists for 
several days in spite of careful diet and treatment, it is safest to restore 
the child to the breast. When this cannot be done, we must select that 
form of artificial diet which seems most suitable. The best is, in our 
opinion, the cow's milk prepared with the solution of gelatine in the man- 
ner already recommended, but made very weak for a few daj^s. We have 
often found it necessary, under these circumstances, to add four and even 
more parts of water to the milk, instead of two or equal parts, as is the 
usual custom. 

In older children the diet, for a few days, ought to consist of simple 
milk and water, or of thin preparations of arrowroot, rice flour, sago, 
tapioca, or wheat flour, made with milk, or milk and water, with small 
quantities of bread, or, if the child refuse such articles, panada, or light 
chicken or mutton water may be allowed. The quantity of food, what- 
ever it be, must be determined very much \>y the child's instincts. When 
the appetite continues, we can seldom go wrong in allowing as much of 
these simple foods as the patient will take. Still, the physician ought to 



364 ENTERO-COLITIS. 

know accurately the amounts that are given, and if he finds the patient 
taking a full healthy average, or more, it will be best to restrict the quan- 
tit} T somewhat, and offer water frequently, on the supposition that the 
little patient is taking its liquid food more from thirst than hunger ; or 
else increase the water of the food, if he have reason to believe that the 
solid matter is in too large a proportion. 

Therapeutical Treatment. — We have found a large number of the 
mild cases that have come under our notice to recover under very simple 
treatment. When the patient is an infant at the breast, before the period 
of dentition, the simple direction not to allow it to nurse as much as 
usual ; the use of a warm bath morning and evening, if the skin be heated 
and the child restless and fretful ; the administration of a small close of 
castor oil (half a teaspoonful to a teaspoonful), or of spiced syrup of rhu- 
barb in the same quantity, with half a drop to a drop of laudanum, at the 
beginning of the attack, to remove any undigested food that ma} r be lying- 
in the bowels, followed in one or two clays, if the disorder continues, by 
some simple astringent remedy ; generally suffices to effect a cure. When, 
on the contrary, the case depends on an unhealthy or insufficient milk, 
when the child subsists entirely on artificial food, and when the disease 
coincides with the process of dentition, the attack is kept up and aggra- 
vated by these causes, and it is more difficult to obtain a cure. In the 
former case the diet is, of course, of all importance ; in the latter the gums 
must be carefully examined, and if found to be swelled and inflamed, and 
the teeth near the surface, the}^ should be freely incised. After these 
matters have been attended to, the kind of treatment will depend on 
the character of the general symptoms and the violence of the enteritic 
disorder. 

When the pain is violent, the discharges frequent, painful, and mixed 
with mucus, muco-pus, or blood, and the abdomen tense and painful to the 
touch, moderate local depletion by leeches may be used with advantage 
and safety in vigorous children. The leeches are best applied over the 
lower part of the abdomen. About six or eight American leeches, or two 
foreign ones, may be applied at the age of one or two years, so as to take 
about two ounces of blood. Of late years, however, we have not em- 
ployed depletion so much as formerly, but use instead warm baths, poul- 
tices to the abdomen, or warm stupes, and refrigerant medicines. Small 
doses of the sulphate of magnesia and laudanum are very useful ; or we 
may employ spirit of nitrous ether, or solution of the acetate of ammonia 
with paregoric or laudanum, or the following mixture : 

R. — Sodas Bicarb., ...... ^ss. 

Mass. Hydrarg., ...... gr. iij. 

Tr. Opii Camph , gtt. l velfgj. 

Syrup. Simp., ...... fgij- 

Aq. Mentha, ...... f ^xiv. — M. 

Dose, a teaspoonful every three or four hours. 

The warm bath, used at a temperature of 95° to 91°, twice or thrice a 
clay, is most excellent. It is a good plan to wrap the child, immediately on 



V THERAPEUTICAL TREATMENT. 365 

being taken out of the bath, in a warm muslin sheet, and over this a light 
blanket, and let it lie on the lap or bed for twent} r minutes or half an hour. 
The hot poultice or stupe recommended above, should be covered with 
oiled silk, secured lry a towel pinned around the bod} T , changed every 
three or four hours, and kept on for the greater part of the day, or for 
several days. 

Calomel has been so highly recommended and so long employed in 
these cases, that we feel some hesitation in saying how often it has dis- 
appointed us. Certainly we have found in many children that it was of 
no evident use, and in the old-fashioned doses of a grain or half a grain, 
we think it only adds to the irritation of the bowels. In doses of the 
twelfth and eighth of a grain, with chalk and opium, every two or three 
hours, we formerly thought it was sometimes useful, but we cannot resist 
the impression which years have given us, that the useful agents in these 
instances, have been the chalk and opium, and especially the opium. 
The blue pill mixture, recommended above, we still put trust in. Why 
blue pill should answer where calomel irritates, we do not pretend to ex- 
plain, but such is the opinion to which experience has led us. 

Before quitting this question of the use of mercurials in diarrhoea, we 
wish to quote the results at which some of the more modern observers 
have arrived, with the remark, as we pass on, that our own conclusions 
were much the same ten } T ears ago as those expressed above. We shall 
do this even at the risk of being tedious, for we think the point a very im- 
portant one. In the first place, we shall quote the opinion of one of the 
ablest of the United States army surgeons, as to the use of this drug 
during the late war. The writer {Outlines of the Camp Diseases of the 
United States Armies as observed during the Present War, by J. J. 
Woodward, M.D., Philadelphia, 1863), in the article on Chronic Diar- 
rhoea, a disorder closely akin in many of its S}'mptoms and anatomical 
lesions to the entero-colitis of children, ssljs at page 262 : " Among the 
remedies liberally employed in chronic diarrhoea, is one group which can 
only be mentioned with disapprobation. This is the mercurials, which are 
too frequently administered to gentle salivation in the form of blue pill or 
calomel, combined with opium and ipecacuanha. The authority of some 
of the most distinguished American medical writers is in favor of the 
enrployinent of mercurials in the chronic diarrhoea of civil life ; yet when 
it is remembered that even those modern writers, who most warmly ad- 
vocate their general employment in the treatment of inflammation, recom- 
mend them to be discontinued as injurious whenever the process has 
gone on to ulceration, it would appear that even sound mercurialists would 
avoid using them in the form of chronic diarrhoea, which is most common 
in the army. 

" Practically it will be found that although in some cases mercurials may 
succeed, as much less dangerous remedies would have done, in checking 
the progress of the disease, yet that in the majority of cases their employ- 
ment is accompanied by an increase of the debility, the loss of appetite, 
the anaemia, and the general constitutional s} 7 mptoms, without any dimi- 
nution in the frequency of the stools. They are, therefore, to be regarded 



366 ENTERO-COLITIS. 

as dangerous and inefficient, and their use in these cases has been com- 
pletely abandoned by those surgeons who are most successful in the 
treatment of the disease." 

Dr. T. K. Chambers, of London (Clinical Medicine. London, 1864, 
p. 51*7), in considering the treatment of diarrhoea in which the stools 
exhibit the products of acute inflammation, says : " The drugs I have 
most trust in are calomel, ipecacuanha, and carbonate of soda. Of the 
first and second equal quantities, and a double quantity of the third, 
ma}' be made into powders, of which from four to six grains, according 
to the child's age, may be given every three hours. This is a tradition- 
ary powder, but it is right to say that I have in a good many instances 
lately left out the calomel, and the case has done just as well, if not better, 
without it." 

Dr. J. L. Smith, of New York (op. cit., p. 379), saj's nothing whatever 
about mercurials in his article on the treatment of inflammatory diarrhoea, 
from which we are led to suppose that he does not use them. He how- 
ever quotes Dr. E. H. Parker as giving, when the condition approaches 
that of dysentery, a mixture consisting of about ten grains of blue mass 
rubbed up in two drachms of syrup of rhubarb, to which is added one 
half teaspoonful of paregoric, and four ounces of chalk mixture. Of this 
the close is a teaspoonful every two or three hours. Dr. Parker sa}'S that 
the " blue mass certainly does not act like the calomel, not producing in 
purgative doses so great prostration, and in small doses it does not lessen 
the proportion of fibrin in the blood, as is the case with calomel." Dr. 
Smith's comment on this is : "I have never used this mixture, having 
been generally satisfied with the effects of the castor oil mixture." 

It is unnecessary to say an}' more upon the use of mercurials, and 
especially of calomel. We have quoted enough to show that our own 
opinions find us in very good compan}-. 

We regard opium as one of the most valuable remedies we have in^the 
treatment of this disease. In the last edition of this work it was stated 
that some writers objected to its employment in the earl}' stage as in- 
jurious, but that we had not been deterred from using it, except in cases 
presenting manifest signs of cerebral irritation in connection with the 
febrile symptoms ; but that when there has been nothing more than irri- 
tability, restlessness, and insomnia, when there was evident pain during 
the discharges, and when the latter have been very frequent, we had 
alwa}'S made use of some of its preparations without hesitation, and cer- 
tainly without injury, but on the contrary, with very great benefit. Our 
longer experience confirms us in this view and practice. The propriety 
of using large doses of opium in the earl}' stages of cholera infantum 
ma}^ well be questioned, as it has come to be by some of the best observers 
in Asiatic cholera ; but this matter will be considered under the head 
of that disease. In the disorder under consideration, which is one of an 
inflammatory catarrhal type, we have never seen the moderate use of 
opium do anything but good. When the nervous s}'mptoms are very 
marked, if they be of the kind which denotes disturbance of the reflex 
functions of the nervous s} 7 stem rather than those indicating cerebral 



THERAPEUTICAL TREATMENT. 367 

disorder, we find nothing which answers so well onr purpose as this 
remedy. When, however, there is unusual quiet, tending towards drowsi- 
ness or stupor, with contraction of the pupils, we make use of it only 
with great caution and in very small doses. We are glad to find that 
Dr. Stokes also employs opium without hesitation. He says, "it is a 
remedy that requires caution in its exhibition, but one of great utility." 
It generally lessens the number of discharges, and very often diminishes 
the heat of skin and frequency of the circulation, by allaying the irrita- 
bility of the nervous system, while at the same time it greatly promotes 
the comfort of the child. We have used it in the form of laudanum or 
paregoric, given in combination with a laxative early in the case, or by 
enema, and afterwards in that of the Dover's powder or powdered opium. 
For a child under six months old half a drop of laudanum is enough to 
give by the mouth. Of the Dover's powder about a sixth or eighth of a 
grain may be administered mixed with two grains of chalk, to be repeated 
every two or three hours until three or four doses have been taken, or 
until the child shows some degree of drowsiness from the action of the 
opium, after which it ought to be suspended for six or eight hours, and 
then resumed. Or the opium may be given in the form of laudanum 
combined with the sulphate of magnesia as recommended above. The 
old-fashioned castor oil emulsion, in the proportion of one drachm in a 
one or two-ounce mixture, with half a drop of the deodorized laudanum 
to each teaspoonful of the mixture, is often very soothing and benefi- 
cial. When there is marked tenesmus, with frequent small evacuations, 
opium may also be used with great advantage by the rectum, either to 
the exclusion of any in the mixture, or in addition to that, taking care to 
graduate the quantity by the degree of drowsiness that may be induced. 
At one year two drops in one or two teaspoonfuls of water or thin starch- 
water may be used two or three times a da} 7 . In such cases, suppositories 
are sometimes retained better than enemata. A twelfth to a sixth of a 
grain of powdered opium made up with cocoa butter, may be given iustead 
of the injection. 

Generally speaking the acute constitutional symptoms either subside 
or disappear under the above treatment, and very often the diarrhoea also 
ceases and the child recovers. When, however, the diarrhoea persists, it 
is necessary to resort to two other classes of remedies, upon which great 
reliance is placed in the treatment of this affection. These are astringents 
and absorbents, of which the most important are prepared chalk, pow- 
dered crab's-e3 7 es, acetate of lead, rhatany, kino, and catechu. The chalk 
may be used in the form of the officinal mistura cretse, a teaspoonful of 
which is given after each loose evacuation, or several times a da} T . When 
the case is severe, the efficacy of this remedy is much increased by the 
addition of tincture of krameria, in the proportion of a drachm to two or 
three ounces of the mixture, of some opiate preparation, or of ten or fif- 
teen drops of the aromatic syrup of galls (to be described presently) to 
each teaspoonful. Chalk may be used also with great advantage, as 
stated above, in powder, combined with Dover's powder. 

The powdered craVs-eyes will sometimes arrest cases in which prepared 



368 ENTERO-COLITIS.. 

chalk fails to produce any effect. It is generally employed in mixture. 
The formula we employ is the following : 

R. — Ocul. Cancror. Pulv., gj. 

Pulv. Acacise, ....... gij. 

Sacch. Alb., J)j. 

• Aqua? Fontis, Aquae Cinnamom., aa . . f^iss. — M. 

A teaspoonful to be given four, five, or six times a day. 

M. Bouchut recommends the following prescription of Hufeland's : 

R. — Ocul. Cancror. Pulv., gr . x. 

Aquae Foeniculi, Syrup. Rhei, aa . . . f^ss. — M. 

Give a teaspoonful every hour. 

Subnitrate of bismuth has been highly recommended, for a number of 
years past, as a remedy in diarrhoea. Dr. Woodward {op. cit., p. 258) 
quotes Assistant-Surgeon Dr. John B. Trask, TJ. S. A., as lauding it very 
highly in the chronic diarrhoea of the armies during the late war, and in 
California and Oregon, especially in those cases in which there is nausea 
or other disorder of the stomach. Dr. Woodward states that " he has 
given it a fair trial, and while he is far from regarding it as a specific, 
believes it to be a most valuable article in both simple, irritative, and in 
chronic diarrhoea." Dr. Trask prefers to give the whole quantity for the 
day in a single dose ; but Dr. Woodward states that this view does not 
correspond with the general experience on the subject. It may be given 
in doses of one to two grains, to children one year old, everjr two or three 
hours. It can be administered in powder with sugar alone, or combined 
with prepared chalk, or in mixture with simple syrup, or ginger or acacia 
syrup, and some aromatic water. We have employed it quite frequently, 
but, on the whole, have not found it so effective as we had been led to 
hope. 

Acetate of lead has been highly extolled by many writers in the treat- 
ment of the diarrhoeas of children. We have had but little experience in 
its use, and are, therefore, unable to offer an opinion in regard to the 
influence which it may exert. It may be given in doses of from a sixth 
to an eighth of a grain, alone, or combined with chalk or Dover's powder, 
every two hours. Krameria, kino, and catechu may be exhibited alone, 
in the form of infusion or solution, or they may be given in conjunction 
with the chalk mixture. We have frequently emploj^ed the tincture of 
krameria in the latter way, and believe it adds very much to the efficacy 
of the remedy. About one or two drachms ma} 7 be added to two ounces 
of the mixture, and the usual dose given. We have used, with much 
advantage, either alone or with chalk or crab's-eyes mixture, an aromatic 
syrup of galls, in the dose of from fifteen to forty drops three or four times 
a day, or, when the discharges are very frequent, every two or three hours. 
It is prepared according to the following formula : 



THERAPEUTICAL TREATMENT. 369 

R.— Gallae Opt. Pulv., gss. 

Cinnamom. Pulv., ^ij. 

Zingib. Pulv., £ss. 

Spts. Vini Gall. Opt., Oss.— M. 

Let the ingredients stand in a warm place for two hours, and then burn off the 
brandy, holding some lumps of sugar in the flames. Strain through blotting-paper. 

Dr. Eberle (loc. eit., p. 221) highly recommends the root of the ge- 
ranium maculatum. He says it makes an "agreeable and efficient astrin- 
gent," and is less apt to derange the digestive organs, and occasion irri- 
tation of the mncons membrane of the bowels, than kino. He uses it in 
the form of a decoction made with milk, by boiling an ounce of the fresh 
root in a pint of milk until half is evaporated. The dose is from a tea- 
spoonful to a tablespoonful four or five times a day, according to the age 
of the patient. 

The nitrate of silver is highly recommended as a remedy of late years 
by several writers. It is given both internally and by enema. The 
modes of administration will be described in the remarks on the treat- 
ment of the chronic form of the disease. 

Revulsives are often of much service in the treatment of this, as of 
almost all the diseases of childhood. When there is much restlessness 
and irritability, with heat of the head and trunk, and coolness of the 
extremities, it will be found that mustard foot-baths, or sinapisms to the 
extremities, often alla}^ these symptoms, and greatly comfort the little 
patient. When the abdomen is tense and painful, and the discharges 
preceded or accompanied by movements or crying indicative of pain, the 
application of a poultice of mush and mustard from time to time, to be 
followed by a simple mush poultice, sometimes acts very usefully. 

Tonics and stimulants are often necessary in weak and delicate children 
from an early period in the attack, and in those who are stronger, after the 
disease has lasted for some time, and the acute symptoms have ceased, and 
been followed by weakness and exhaustion. The best tonic is, probably, 
sulphate of quinine, in doses of from a quarter of a grain to a grain three 
times a clay, continued for one, two, or three weeks, if necessary. Old 
brandy has answered better in our hands as a stimulant, than wine, wine- 
whey, or any of the tinctures. It may be given to the youngest children 
in doses of from five to ten drops every two hours, or a teaspoonful may 
be added to a wineglassful of sweetened water, and a teaspoonful given 
whenever the child will take it. We have been obliged, in several cases, 
to continue the use of the brandy for three, four, and five weeks. At the 
time when we are obliged to resort to this class of remedies, it is almost 
always necessary also to pay attention to the improvement of the diet. 
The proportion of milk to water ought to be increased, if it has been 
small heretofore ; and we should employ every means to induce the child 
to take a sufficient quantity without overloading the stomach. At this 
stage small quantities of animal broths are proper, or the child maj r be 
allowed to suck pieces of juicy meat, or to eat very finely minced meat 
of chicken or mutton. The diet is in fact a most important part of the 

24 



370 ENTERO-COLITIS. 

treatment at this period. Dr. Stokes says of it, that " many children are 
lost by the practitioner neglecting this point." 

Occasionally, indeed quite frequently, vomiting becomes a most trouble- 
some symptom in entero-colitis. When it occurs at rare intervals, and 
without much distress to the patient, it needs no attention, since it is to 
be supposed that the physician has already arranged the Irygienic and 
therapeutical treatment so as to suit the ordinary conditions of the dis- 
order. But when vomiting becomes frequent and violent, so that the 
child rejects a large proportion of all that is given to it, and when, be- 
tween the acts of vomiting, the little thing refuses almost everything that 
is brought to it, all its usual foods, medicines, and sometimes even water, 
it is evident that the child has a more or less positive sense of nausea 
which causes loathing of food, and the s3'mptom becomes a serious com- 
plication which requires special attention and treatment. In such cases 
there is no use in forcing food or drugs which it loathes upon the child, 
unless all other means have failed, when of course, we must attempt 
to make it take concentrated foods in small doses. The better plan, 
at first, is to change the diet in toto — to abandon milk and all its prepa- 
rations for two or three days, if these excite disgust — and give light beef 
or chicken tea, just touched with salt, or raw beef, or, if this also is re- 
fused, cold extract of beef in one or two tablespoonful or wineglassful 
quantities, or pieces of juicy and rich beef very slightly cooked, to be 
sucked. Or we maj T try small portions of yelk of egg^ hard boiled, or 
what we have often found was eagerly taken in such conditions, wine- 
whej T , of which we have given, in the second year of life, as much as a 
tumblerful in twenty-four hours, and this without the slightest effect of 
undue stimulation, febrile heat, or excitement. Sometimes, when the 
child refuses its ordinary milk persistently, or vomits it so soon as taken, 
it will drink willingly, and retain very well lime-water and milk, in the 
proportion of one of the former to two or three of the latter, with just 
enough brandy to change the taste. We know that some medical men 
object entirely to the use of stimuli in children on two grounds : 1. That 
alcohol has no remedial power whatever, or that it is positively injurious 
in all cases. 2. That its use tends to produce that pernicious taste for 
stimulants which engenders the habit of drunkenness. To the first ob- 
jection we can only reply that our observation and experience have led us 
to a different conclusion, and that, when employed in certain conditions 
of the vital powers, which we have carefully endeavored to describe, 
stimuli are of the highest value as a therapeutic means. To the second 
we reply that we have never, so far as very careful observation goes, pro- 
duced a drunkard by any use we have made of them. We agree that 
physicians ought to be very careful not to employ them in any attractive 
form, as a long-continued remedy, in children over six or eight years of 
age. When we desire to use any form of alcohol in a chronic case in chil- 
dren over the age mentioned, we alwa3 r s give some of the bitter tinctures 
or elixirs. When possible, we alwa}^s order the oldest and most delicate 
brandy that can be procured. As to the quantity, this must depend on 
the age of the patient, the instinct and idiosyncrasy of the child, and the 



THERAPEUTICAL TREATMENT. 371 

degree of severity of the case. At the age of six months, from ten to 
fifteen drops may be given every two or three hours in two or three 
ounces of the lime-water and milk ; and at one and two years, from twenty 
to twenty-five drops in from four to six ounces of the milk food every two, 
three, or four hours. It may be a sign of the old Adam in the poor little 
sufferer, but we have often known children to take, for days together, 
milk with brandy in it, who would not touch the milk without this addi- 
tion. We cannot but think that in such cases it is an instinct for a use- 
ful agent, like the appetite of patients in typhoid or typhus fever, in 
certain of their phases, for wine or brandy, which disappears when the 
necessity for it passes away, as has been so well described by Dr. Cor- 
rigan, of Dublin, in his able little essay on the treatment of Irish typhus. 
Under these circumstances, all medicines which disgust the child must 
be laid aside. A bitter, or nauseous, or gritty dose will, in such states, 
surely cause vomiting, as will, in older persons, under such conditions, an 
odor or taste, or even an idea. We have seen a little infant, sick with 
diarrhoea, who was sitting languidly upon the floor, made to gag and retch, 
by chancing to pick from the floor a piece of softened bread. The im- 
pression produced upon the tactile sense of the fingers by the wet and 
mush}" substance caused sickness at once, as the filing of a saw sets the 
teeth of a delicate nature on edge, and brings water into the mouth. All 
offensive and bitter doses must be abandoned therefore. We have often 
used, in such cases, the following prescription with much benefit : 

• R. — Liq. Morph. Sulphat., ..... Tt^xxxij. 

Acid Sulph. Dil., njj xv . 

Curacoa, f ^ij. 

Aquae, ........ fgxiv. — M. 

Dose, a teaspoonful every hour or two hours, at the age of six months to a year. 

For older children, the proportions of the opiate and acid must be in- 
creased. When the nausea subsides or passes away, or when the child 
becomes drowsy, the intervals between the doses must be lengthened, and 
as the symptoms disappear, the other remedies necessary for the diarrhoea 
ma} 7 be resumed, and so too of the food. Dr. J. L. Smith, of New York, 
states that the best remedy he has used for vomiting is the neutral mix- 
ture, as follows : 

$. — Potass. Bicarbonat., gr. xxv. 

Acid Citric, gr. xvij. 

Aquaa Amygd. Amar., .... f^j. 
Aquae, fgij.— M. 

One teaspoonful to a child from eight to twelve months old, repeated according to 
the nausea or vomiting. 

Creasote is also sometimes very useful. Dr. Smith says that in the 
Nursery and Children's Hospital of New York, this remedy is used, given 
in the proportion of an eighth of a drop in a teaspoonful of lime-water T 
in a teaspoonful of milk or breast-milk, and has been found successful iu 
a certain proportion of cases. 



372 ENTERO-COLITIS. 

Treatment of Chronic Entero-colttis — The management of the 
hygiene of the patient is more important than any other part of the treat- 
ment, in this, as in nearly all the diseases of the digestive organs in chil- 
dren ; for cases will often recover when the diet, drinks, and exercise are 
property regulated, without the use of any drugs whatever, whereas, most 
assuredly, but a small proportion of them would terminate favorably under 
the best and wisest therapeutical medication, were the hygiene of the child 
neglected. The remarks that have been made as to the diet most proper 
in the acute form will apply here. If the child have been weaned only a 
few weeks before the time at which we are consulted, and the case is at all 
serious, it is better to advise the procuring of a wet-nurse. We have 
several times known cases of the disease which had resisted the most 
carefully managed artificial diet and therapeutical treatment, recover in 
a few da}'s after the child had been restored to the breast. It is often, 
however, impossible to follow this course, from the refusal of the parents 
to obtain a nurse, or of the child to take the breast of a stranger, and we 
are obliged to rest content with artificial food. We believe that the kind 
of diet which suits the largest number of children is one of milk. During a 
number of years past, we have found the gelatine food, already described, 
to answer better than any that we have ever essayed. It ought to be made 
very light and thin. About a scruple of gelatine should be dissolved by 
boiling in half a pint of water. Towards the end of the boiling, a gill of 
cow's milk, and a teaspoonful of arrowroot made into a paste with cold 
water, are to be stirred into the solution, and from one to two table- 
spoonfuls of cream added just at the termination of the cooking. It is 
then to be sweetened moderately with white sugar, when it is ready for 
use. The whole preparation should occupy about fifteen minutes. 

When cow's milk, mixed with water alone, or prepared in the manner 
just recommended, evidently disagrees, we have sometimes found cream 
with water alone, or better still, with the solution of gelatine in water, in 
the proportion of one part of cream to five or six of the latter, to suit 
very well. In other cases very carefully prepared beef-tea or chicken or 
mutton water, given several times a day or but once, according to the 
taste and fanc}^ of the child, will answer better. It sometimes happens 
that the child will refuse everything that has been mentioned, and } T et the 
prostration and emaciation are such as to make it essential to procure 
some aliment that it will consent to take. We have, under such circum- 
stances, given small portions of bread and butter, or stale sponge cake, 
with weak brandy and water, if the child is old enough to swallow solid 
food. Sometimes it will eat small quantities of meat, and when this has 
been the case, we have not hesitated to allow a chicken-bone, with a little 
meat attached to it, or a piece of ham, or better still, a portion of roast 
beef, or of the tender loin of beef-steak, to be held in the hand and sucked ; 
or we inay give the white meat of chicken cut up very fine, or torn into 
the finest shreds. Of the latter about a teaspoonful is sufficient for the 
first da}^, given with a little brandjr and water. The quantity can be 
gradually increased afterwards. We have of late j^ears also given small 
quantities of raw beef in many cases, minced very fine and flavored with 



TREATMENT OF THE CHRONIC FORM. 373 

salt, or prepared in the manner described below, 1 and have found it to be 
readily digested and to agree well with the little patients. There is another 
article which we have sometimes giYen when children have been exhausted 
for want of food, and when the} T require constant change in order to be 
tempted to take it. This is the } T elk of a hard-boiled egg, which has the 
advantage of being very nutritious if digested, and of not being injurious 
should it happen to pass into the bowel in the crude state, as it falls into 
a state of fine powder, which is not irritating to that organ. 

The quantity as well as quality of the food is of the utmost importance, 
and should be strictly regulated by the physician, and attended to b} r the 
mother or nurse. As a general rule the child may be allowed as much as 
it wants of proper food, since the appetite is almost always greatly dimin- 
ished, and it is not likely, therefore, that too much will be taken. If, 
however, there is disposition to nausea or vomiting, or if the appetite 
remain as good as usual, the quantity must be restricted. The difficulty 
in most cases is to get the patient to take enough, and not to prevent it 
from taking too much, for we have very often ascertained, upon careful 
inquiry, that the quantity was entirely too small to support the strength 
of the constitution. A hearty child, six months old, fed solely on arti- 
ficial food, will generally take a quart of food in the twenty-four hours, 
while at a year old it will take usually fully a quart or three pints of fluid 
nourishment, besides eating small quantities of solid food. Now, we have 
frequently known children laboring under chronic entero-colitis, not to 
take more than one or two gills of food in the day, which is manifestly 

1 The use of raw meat in the diarrhoea either of infants deprived of their mothers' 
milk, or of weaned children, was recommended by "Weisse, of St. Petersburg, as long 
ago as 1840 (Oppenheim's Journal). Of late years it has been extensively used with 
excellent results, and is highly praised by Trousseau and other eminent authorities. 
The administration of the muscular tissue itself appears much more useful than any 
form of beef essence or soup, probably for this reason among others, that these fluids 
pass too quickly through the intestinal canal. The best meat for the purpose is the 
fillet of beef, though fine mutton may also be used. It should be cut very fine, and 
according to Trousseau, pounded in a mortar and strained through a sieve or cullen- 
der; the pulp, thus separated from the cellular texture of the meat, may be rolled 
into small balls in salt or powdered sugar. 

The quantity upon the first day should not exceed three drachms, given in divided 
doses ; but it may be doubled on the successive days, until young children may take 
from six to ten ounces a day. Under this regimen the diarrhoea frequently ceases, 
and the children quickly recover their plumpness and natural spirits. 

Trousseau calls attention to the fact that the stools are frequently red and fetid at 
first, even when the nature and abundance of the diarrhoea have already undergone 
a favorable change. 

In a second article upon this subject (Jour, fur Kinderkrankheiten, January and 
February, 1858), Weisse calls attention to the fact that in many children who had 
been treated by raw beef, tape-worms have been developed. As these worms were 
all specimens of taenia solium, which is not indigenous in St. Petersburg, it is prob- 
able, as suggested by Von Siebold, that they had been conveyed in the undeveloped 
state in the flesh of oxen, brought from distant points. We are not aware that this 
unfortunate consequence has been observed frequently in other localities, and cer- 
tainly in the quite numerous cases in which we have ourselves administered raw 
meat to children, no entozoa have been developed. 



374 ENTERO-COLITIS. 

much too little. TVheii this is the case, therefore, we should alwaj T s en- 
deavor to stimulate the appetite and digestion b} T means of tonics and 
stimulants, and by causing to be presented to the child such a variety of 
food as ma} r entice it to take a larger quantity than before. 

In connection with this most important matter of the food, we will 
again quote from Dr. S. B. Hunt (op. cit., page 305), to show the results 
of his experience in the use of foods in chronic inflammatory diarrhoea in 
the army. For the sake of any non-professional reader, we will state 
that by albuminoid food Dr. Hunt refers to meat, meat-broths, eggs, &c. ; 
and by antiscorbutic food he means tomatoes, fresh fruits, onions, &c. 
Dr. Hunt sa} T s: "The value of drugs, was, perhaps, over-estimated in 
this as in all other diseases of assimilation, and only a careful avoidance 
of the original causes of the malady, and an equally careful recognition 
of their continued existence in the system, could secure any degree of 
success. The scorbutic and malarial taints were almost uniformly pres- 
ent, the former very frequently in as pronounced a form as the latter. 
The bowels, enfeebled by the inflammatory process, were unable to per- 
form their normal function of the digestion of starches, and the diet, 
therefore, became necessarily albuminoid. A full nutritious diet of albu- 
minoid and antiscorbutic food assumed the first importance in the treat- 
ment. Coupled with this came pure air and absolute cleanliness. And, 
with these Ixygienic measures alone, when they could be properly en- 
forced, it was possible to treat chronic diarrhoea and dj'senteiy with a 
fair degree of success, even in the great heats of a Southern summer." 
These views confirm what we have said above, that milk, meat, raw or 
cooked, broths, eggs, ginger-bread, tomatoes, bread and butter, and we 
ma} r add currant-jell}', make the best food for children over two and three 
years of age. Even in children of eight months and a year or upwards 
of age, milk and beef or chicken tea, ought to form the chief diet. The 
starches, such as arrowroot, barlej^, wheat preparations, &c, do not an- 
swer, except in very small quantities cooked in milk. We saw one child, 
a } T ear old, weaned in August in consequence of the illness of the wet- 
nurse, whose life was apparently saved in dj'sentery by Liebig's cold 
extract of beef, and by its fortunately having developed a strong taste 
for the sucking of large pieces of rapidly and slightly cooked beefsteak. 

The therapeutical treatment of the chronic form consists principally in 
the administration of tonics, astringents, and absorbents. Of these the 
most important are the powdered chalk and crab's^es, and the different 
vegetable astringents, which have already been noticed in the remarks on 
the acute form. These are to be given in the manner there recommended, 
and it is therefore unnecessary to repeat what has already been said. In 
addition to these there are some remedies which are particularly adapted 
to the chronic form of the disease. Amongst them are nitrate of silver. 
Dr. Eberle {pp. cit., p. 251) sa} T s he has found its internal administration 
to produce the happiest effect in a few instances. His prescription was 
a grain of the nitrate dissolved in an ounce and a half of gum arabic 
water, with the addition of twenty drops of laudanum. The dose was a 
teaspoonful three times a day. He adds that he has never "known the 



TREATMENT OF THE CHRONIC FORM. 375 

slightest inconvenience to result from the use of this article in chronic 
mucous inflammation of the bowels, when administered in a mucilaginous 
solution and in very small doses." It has been much used of late years 
in France. MM. Trousseau and Pidoux recommend its internal use in the 
chronic diarrhoeas of children occurring during dentition, after bismuth, 
powdered crab's-eyes, and diet have failed to effect a cure. Their formula 
is as follows : 

R. — Argent. Nitrat., gr. i. 

Aquae Destillat., f ^vj. 

Syrup. Sarsap., f^ijss. — M. 

To be given in eight or ten doses. 

At the same time they employ an enema composed of a grain of the ni- 
trate in three ounces of distilled water. It is highly recommended also 
in these cases by Hirsch, of Konigsberg. His formula is as follows : 

R. — Argent. Nitrat. Crystall., . . . gr. $. 

Aquse Destillat., ..... f^ij. 

Acacioe Pulv., ..... ^ij. 

Sacch. Alb., gij.— M. 

A teaspoonful of this mixture to be given every two hours, and an enema, 
consisting of a quarter of a grain of the salt, with mucilage and a little 
opium, to be administered (Banking's Abst, No. vi, p. 61). We have 
employed this remedy in the proportion of from half a grain to a grain 
in a gill of water, by injection, morning and evening, for several days, 
with very decided benefit, in three cases of diarrhoea following summer- 
complaint, in which the stools were frequent, mucous, sometimes streaked 
with blood, and accompanied by tenesmus. 

Dr. Woodward (op. cit., p. 264) says, in his article on the treatment of 
the chronic diarrhoea, which was a true entero-colitis, that "by far the 
most valuable local measure is the employment of solutions of the min- 
eral astringents as enemata." He mentions sulphate of copper, nitrate 
of silver, sulphate of zinc, and acetate of lead, but thinks that the sul- 
phate of copper and nitrate of silver are probably the most efficient. The 
strength he recommends is of one or two grains to the ounce of water, 
of which from one to six ounces may be thrown into the rectum two or 
three times a day. He advises that, when the rectum rejects the injec- 
tion immediately, twenty to forty drops of laudanum be added to each 
enema, that the injection be thrown carefully into the bowel, and the 
nozzle of the syringe be withdrawn as gently as possible, in order that 
the fluid may be retained at least for some little time. We quote these 
statements, not to induce the use, in children, of solutions of one or two 
grains to the ounce, but to draw attention to one of the means the ability 
and advantage of which bore the test of the vast army experience in this 
most severe and troublesome disease. In children it is best to begin with 
a grain to four ounces, and, if this gives no pain, or but little, and does 
not produce the hoped for benefit, the proportion may be doubled, or, 
after two or three trials, brought up to that of a grain to an ounce. 



376 ENTERO-COLITIS. 

Another excellent remedy in the chronic diarrhoeas of children, one 
from which we have sometimes obtained very satisfactoiy effects, is the 
syrup of the nitrate of iron. It is given in doses of from two to five 
drops three times a day, in sweetened water, at the age of one or two 
years. 

The following formula is recommended by Dr. Eustace Smith. We 
have used it ourselves in several chronic cases, and have been much 
pleased with its effects : 

R. — Liq. Ferri Pernitrat., .... f^ss. 

Acid. Nitric. DiL, f3 ss - 

Syrup. Zinzib., fgj. 

Aq. Anethaa, ad f^iij. — M. 

A teaspoonful every six hours at one year of age. 

We have found a teaspoonful every three or four hours not too much 
at three and four years of age. 

Creasote also has been recommended of late years, and is highly thought 
of by some practitioners. It may be given in doses of from a quarter to 
half a drop every three or four hours at a year old. Bouchut recommends 
enemata of from ten to twelve grains of extract of rhatany, or six to ten 
of tannin, in about five to seven ounces of some vehicle. 

Dr. Pollak, of St. Louis (Trans. Amer. Med. Assoc., vol. viii, p. 260), 
speaks in the highest terms of the efficacy of sulphuric acid in diarrhoea. 
He thinks that he has succeeded in establishing, beyond cavil or doubt, 
"the almost specific effect of sulphuric acid in all cases of diarrhoea. I 
sa}^ in all cases of diarrhoea, and in diarrhoea only, for I hold it is less 
reliable, and even frequently injurious, in dysentery." He sa} T s, speak- 
ing of adults, that " the majority of cases were cured in 24 or 48 hours ; 
few required the use of it for four days, and only a very small number 
took it as long as eight days ; they got nothing else, and were cured." 
He also states he " could successfully prove, that in the much and justly 
dreaded summer-complaint of children, in cholera infantum, it is much 
preferable to the mercurial, chalk, astringent, and opium treatment; it is 
even more rapid and more positive in its effects with children than with 
adults." 

The dose he gives to adults is usually half a drachm of the aromatic 
sulphuric acid every four hours, and he remarks that from four to eight 
doses generally sufficed to effect a cure. His usual formula (for adults) 
is as follows : 

R. — Acid. Sulph. Arom., .... fgss. 
Tinct. Cardamomi Comp. (or Sp. Lav- 
andulae Comp.). Syrupi Simp., aa, . f^j.— M. 

The dose is printed two tablespoonfuls every two hours, but this must be 
an error of the printer; two teaspoonfuls must be the dose intended. "If 
there be tormina, feeble pulse, general prostration, I added aq. camphorse, 
f^j, and gave it in shorter intervals." Dr. Pollak adds, that "the first 



TREATMENT OF THE CHRONIC FORM. 377 

dose is almost invariably ejected, probably from its suddenly astringing 
the stomach. I then ordered iced water to drink ad libitum, in order to 
soothe and distend mechanically the stomach; had the dose repeated im- 
mediately, and have never seen it returned afterwards." Dr. Pollak does 
not inform us of the doses he employs in the case of children. We may 
suppose, however, that for a child of two or three years old, half a tea- 
spoonfnl of the above mixture, and for a younger child a yet smaller 
quantity, would be quite enough. 

We have never used sulphuric acid in such large doses as the above, 
but for some years past have been in the habit of employing it in the fol- 
lowing mixture with excellent results. In cases of diarrhoea showing a 
disposition towards dysentery, as often occurs in entero-colitis, and espe- 
cially when the stomach has been irritable, so as to bear other medicinal 
substances badly, we have found this combination very beneficial. 

R. — Acid. Sulph. Arom., .... gtt. xlviij. 

Tinct. Opii, gtt. xij, vel xxiv. 

Syrup. Kranieriae, .... f^ss. 

Aq. Fluvial, f ^ijss. — M. 

A teaspoonful every two hours. 

It should never be forgotten in the treatment of chronic diarrhoea in 
children, that the most important point of all is the regulation of the diet 
and other hygienic conditions. We are fully convinced that we have 
seen several children saved from death by attention to these points, and 
by the persevering and careful employment of tonics and stimulants. It 
often happens, after the disease has lasted for some weeks or months, 
that the powers of the stomach are almost wholly lost. The child either 
refuses food or takes so little that the quantity is evidently insufficient 
to carry on the vital processes, or the greater part of what is taken is re- 
jected by vomiting, or lastly, much of it passes off through the bowels, 
and appears in the stools in an undigested state, forming what is called 
lienteiy. If this condition of things is allowed to continue, the emacia- 
tion and exhaustion make rapid progress, and the case must soon termi- 
nate fatally. Under these circumstances all the ingenuity and skill of 
the plrysician are required to find articles of diet of a kind to recall and 
tempt the child's worn-out and often perverted appetite, and which, at the 
same time, may be digestible and nutritious, and tend to restore vigor 
to the digestive function. If the stomach is frequently sick, it is best to 
abandon all remedies but those which are stimulating and strengthening, 
and especially to forbid all such as are in the smallest degree nauseous. 
We would indeed depend entirely on the use of repeated doses of the 
oldest and most delicate brandy that could be found, of which from one 
to two teaspoonfuls may be put into a wineglassful of cold water, and 
the whole given by teaspoonfuls in the twenty-four hours ; or fifteen to 
twenty drop doses of the elixir of Peruvian bark every three or four hours 
may be used ; or Hawley's wine of pepsine, in half teaspoonful doses three 
times a day ; or, two or three drops of tincture of mix vomica in sweet- 
ened water three times a dajr, if the bitterness does not cause nausea or 



378 CHOLERA INFANTUM. 

increase the loathing. In such cases, wine of iron, in doses of twenty 
drops to a fourth of a drachm, with syrup of tolu and caraway water, will 
sometimes do exceedingly well ; or the following, which has sometimes 
succeeded in our hands : 



R.— Tr. Ferri Chloric!., 



f* 



3J' 



Acid Acet. Dil., f 3J. 

Liq. Ammon. Acetat., .... fgij. 

Syrup. Simp., f§ ss - 

Aquas, fgij.— M. 

Dose at four years, a teaspoonful, and under that age, half a teaspoonful three or 
four times a day. 

In some very obstinate cases, especially where there is any reason to 
suspect the existence of a malarial element in the case, from half a minim 
to one minim of Fowler's solution of arsenic, with the wine of iron, three 
times a day, has been very serviceable. While this is being done, an 
occasional dose of anod3 T ne, just enough to tranquillize without stupefy- 
ing, may be given. If the rectum will retain it, it is better to give it by 
enema. In some cases we have found the aromatic syrup of galls given 
with brand}^, to be taken by the child without any difficulty or disgust. 

Exercise by riding and exposure to the air, which, however, must never 
be carried so far as to induce positive fatigue, are all-important. In some 
very severe and tedious cases, change of residence or travelling has been 
known to effect a cure after all remedies and other means had failed. In 
one case, in this city, which had lasted with but short intervals for two 
years, we obtained a perfect cure by persuading the parents to send the 
child into an elevated part of the country in the month of May, where it 
was kept until July, after which it was removed to the seaside until the 
end of August. Nothing was done in the meantime except to regulate 
the diet most carefully, and to keep the child the greater part of the day 
in the open air. 



AETICLE III. 

CHOLERA INFANTUM. 

General Remarks. — In the previous editions of this work we failed 
to draw with sufficient clearness the distinction between what we think 
ought to be called cholera infantum, and the much more common dis- 
orders which are properly styled simple and inflammatory diarrhoea or 
entero-colitis. In this we did but follow the practice of most American 
writers, and the custom of the day. Indeed, many physicians amongst 
us are still in the habit of designating the various intestinal disorders of 
children so frequent during the summer heats, under the common title 
of cholera infantum. We believe that a large majority of the deaths 
registered in our mortality returns under the title of cholera infantum, 



DEFINITION. 379 

are the result not of a true choleraic disease, but rather of simple diar- 
rhoea or eutero-colitis. "We have, however, only too often to contend 
with a disease in children which deserves the title of cholera, which is the 
analogue of cholera morbus, or even of epidemic Asiatic cholera, in the 
adult, and which is the disease we propose to consider in the present 
chapter. 

Definition; Synonymes ; Frequency. — We can define cholera infan- 
tum only by an enumeration of its most specific characters, and we shall 
do this very much in the words in which Dr. Aitken describes epidemic 
cholera. Cholera infantum, as we understand it, is characterized by the 
occurrence almost solely during the summer months, in young and gene- 
rally teething children, who have been previously either health}^ or the 
subjects, for a longer or shorter time, of simple or inflammatory diar- 
rhoea, of sudden muscular debilhVv, occasional nausea, spasmodic griping 
pains in the bowels, depression of the functions of respiration, and an 
appearance of faintness ; copious purging of thin serous fluid, or of large 
watery and fetid evacuations, succeeded by more or less obstinate vomit- 
ing, coldness and dampness of a part or of the whole surface of the body, 
coldness and lividity of the lips and tongue, cold breath, a craving thirst, 
a feeble rapid pulse, difficult and oppressed respiration, with extreme 
restlessness, diminished or suppressed urinary secretion, pallor of the 
entire surface of the bod} T , a sunken and pinched countenance, weak- 
ness of the cry or partial aphonia, and collapse, more or less complete, 
which may prove fatal, or be followed by reaction and a subsequent more 
or less severe and obstinate simple or inflammatory diarrhoea. 

This disease is not so common as simple and inflammatory diarrhoea, 
most cases of which have been "hitherto, as stated above, improperly 
grouped under the common name of summer complaint. Though rare in 
Europe, in comparison with its frequency in this countiy, it is easy to 
recognize from the descriptions, the identity of some of the cases called 
by Billard follicular enteritis, by Barrier apyretic and febrile follicular 
diacrisis ; by Rilliet and Barthez, in their second edition, choleriform 
gastro-intestinal catarrh, and by Copland, the choleric fever of infants, 
with the true cholera infantum of America. 

It is impossible to determine its real frequency amongst us, for the rea- 
son that fatal cases of simple diarrhoea and entero-colitis, are so generally 
included in our mortality returns, with those of the true choleraic disease, 
under the common title of cholera infantum, or summer complaint. That 
it is a frequent cause of death is shown, however, by the tables of Dr. 
Emerson (Am. Jour. Med. Sciences, vol. i, 182t), wherein it appears that 
from 180T to 182*7, 35 16 deaths from cholera, under five years of age, 
were returned in this city; of course many of these deaths were from a 
true choleraic disease. This is the largest number of deaths from any 
one disease given in the table. The next largest item of mortality is 
under the head of convulsions, of which it appears that 3192 died in 
the same period of time. During the five years, from 1S44 to 1S4S in- 
clusive, there occurred in this city, 18,599 deaths, from all causes, under 
fifteen years of age. Of this total, 1611 died of the so-called cholera in- 



380 CHOLERA INFANTUM. 

fantmn, which is the largest number of deaths from any one disease, with 
the exception of convulsions. Of convulsions there died 1729. After 
cholera infantum the largest number of deaths was caused b}~ marasmus 
(1060), dropsy of the brain (1041), pneumonia (772), aud croup (756). 
Cholera infantum, therefore, in these tables, causes nearly as many deaths 
as convulsions during the first fifteen j T ears of life, and rather more than 
twice as many as pneumonia. We also refer the reader to the table given 
at pages 344-345, obtained from the Board of Health of this city, exhibit- 
ing the mortality under five years of age from cholera infantum, diarrhoea, 
and dysentery, with the total mortality at all ages, and with the mean 
temperature of each month. 

Causes. — In discussing the causes of cholera in children, we meet again 
the difficulty so often alluded to, viz., the custom in this country of class- 
ing in mortality returns, all the deaths from intestinal affections in child- 
hood, under the common title of cholera infantum or summer complaint. 
Our own experience leads us to the conviction that the causes are the 
same as those of simple and inflammatory diarrhoea, acting with greater 
intensity. When that cause, or those causes, whatever they maj^ be, act 
with moderate force, the result will probabl} T be a simple or inflammatory 
diarrhoea. When, on the contrary, the causes are intensified in degree, 
the case will be apt to take the form of choleraic disorder. Thus, heat 
is one of the most influential of these causes. So long as the atmos- 
pheric temperature is moderate, the resulting disorders will probably 
take the form of simple or inflammatoiy diarrhoea. But let the tempera- 
ture rise to 85° or 95° Fahr., or even higher, as happens occasionally in 
our summers, and continue at that height for three or four da}-s, and 
children previously well, will be seized with the true choleraic forms of 
diarrhoea, whilst those who are already suffering -with simple or inflam- 
matoiy diarrhoea, are prone to have these milder diseases assume sud- 
denly the choleraic type. 

A glance at the table above referred to, shows most plainly the effect 
of heat upon the mortality from bowel diseases in children, under five 
years of age. It will there be seen that, in the two months of July and 
August, when the mean monthly temperature is between 75° and 80°, 
the mortality from cholera infantum rises to between two and four hundred, 
and even over ; whilst during the cool months, as January, February, No- 
vember, and December, when the mean monthly temperature is between 
30° and 40° generally, only one, two, three, or none at all, are reported. 
This table shows also, what we have so frequently remarked upon, that 
most of the fatal cases of bowel disease in early life, are classed in the 
medical returns of this city, under the common title of cholera infantum, 
whereas, we are sure from our own personal experience, that many of 
these deaths would be more correctly referred to simple or inflammatory 
diarrhoea, or entero-colitis. Thus, in the very months when three and 
four hundred deaths are grouped under the title of cholera infantum, only 
from fifteen to twenty, or a little over, appear usually under the term 
diarrhoea. 

Diet. — Improper diet is another frequent cause of choleraic disease in 



DIET. 381 

hot weather. Sudden weaning, a change in the character of the artificial 
food, the unfortunate use by accident, or by the carelessness of the nurse, 
of unwholesome milk, of improper vegetables, or, as not unfrequently 
happens, of green or unripe or unhealthy fruit, as apples, currants, goose- 
berries or blackberries (instances of all of which we have ourselves met 
with), will sometimes bring on in a very few hours, the most violent at- 
tacks of cholera, or convert a previously mild and comparatively safe 
diarrhoea into the more violent form of disease we are considering. These 
results are especially apt to follow such accidents or imprudences in large 
cities, where the hygienic conditions are alwa} T s in summer of a kind to 
invite the more violent and dangerous forms of intestinal disorder. In 
fine, the conditions which have been ascertained to be most certain to 
produce epidemic cholera, when that disease is present in a locality, are 
those which develop cholera in children. To put before the reader the 
conditions most certain to cause cholera in children, we cannot do better 
than to quote from the Report on Epidemic Cholera to the Citizens' 1 As- 
sociation of New York in 1865, the localizing causes of cholera. 
These are : 

1. Decaying organic matters, bone, hide, fat and offal houses, neglected 
stables, putrescent mud, and filth. 

2. Bad drainage, local dampness, malaria. 

3. Obstructed sewers, filthy streets, gutters, stables, garbage, and cess- 
pools. 

4. Water and beverages in any manner contaminated by putrescent 
organic matter, particularly by any soakage from privies. 

5. Xegiected privies and putrefying excrement. 

6. Overcrowding and neglect of ventilation. 

It is just where these* conditions are most rife that choleraic diseases in 
children are most apt to occur. Amongst the poor, who inhabit the crowded 
quarters of cities, where the streets and alleys are small and narrow, where 
heaps of decajing vegetable and' organic matters abound, where water is 
scant or scantily used, where ventilation, from the manner in which the 
streets are laid out, and from the crowding together of buildings, is nec- 
essarihr imperfect, we have the most numerous and the severest forms of 
the disease. Add to these the small size of the houses, the low ceilings, 
the small and few windows, and the interior arrangement of the rooms, 
which is such that a thorough draught is unattainable, and we need not 
wonder at the prevalence of the disease. It is amongst the poor, too, that 
the food is often of necessity, as well as from ignorance and recklessness, 
of the most improper kind, and not unfrequently, insufficient in quantity. 

But not only the poor, in their unhappy lot, suffer from this disease. 
The children of the rich, with all the advantages of the most wholesome 
lrygienic appurtenances which ease and knowledge can supply, are apt to 
contract it if they remain in town during the hot summer months. So well 
is this known that most families in easy circumstances leave the city for 
the seaside or the interior, so long as their children are young, remaining 
absent usually from the middle of June to the middle or end of September. 



382 CHOLERA INFANTUM. 

It is nevertheless true that, whilst all the residents in our cities during 
the summer season are liable to see their young children suffer from 
this disease, those who are so fortunate as to occupy large and airy 
houses in the best and cleanest quarters, and who follow a wise s} T stem of 
Irygiene as to diet, water, dress, and exposure to fresh air, escape with 
much more certainty- the disease than those who are compelled by the 
necessities of their position to submit to the unhealthy conditions men- 
tioned above. 

Dentition. — We believe this also to be a most powerful predisposing 
cause of the disease, and 3 T et it would seem to be less influential than age, 
for the tables of Dr. Emerson show that it is about twice as fatal in the 
first } T ear as in the second, though the process of dentition is certainly 
more active and continuous in the second than in the first }'ear. We have 
rarely observed it before the beginning of the process of dentition, and it 
is certaiuly very rare after its completion. 

Age, as has just been stated, exerts a strong influence in the production 
of the disease. In the tables of Dr. Emerson, the cases of cholera in- 
fantum and cholera morbus are included under the one head of cholera, 
but as all cases of the disease under five years of age are called cholera 
infantum, the want of the distinction does not make the statements less 
useful to us. From them it appears that there were 2122 deaths in the 
first year, 1186 in the second, and only 268 between the second and fifth. 
Between five and ten years, only 52 cases are noted, and these would of 
course be entitled cholera morbus. In the five years, from 1844 to 1848 
inclusive, of 1611 deaths from cholera infantum under 15 3^ears of age, 
969 occurred in the first 3-ear of life, 529 in the second, 103 between two 
and five } r ears, and only 10 after that age. 

Sex. — There are no large tables of reference, by which to ascertain the 
exact proportion in which the disease occurs in the opposite sexes. It 
would appear, however, from our own experience, to be much more com- 
mon in males than females, since of YT cases of which we have kept a 
record, 48 occurred in bo} T s, and only 29 in girls. 

Constitution. — The disease is most apt to occur in feeble, delicate chil- 
dren, and in those of nervous, irritable temperament. 

Hereditary Predisposition. — Our own observation leads us to believe 
that the disease is apt to occur in certain families. It would seem prob- 
able that this peculiarity must depend on the fact that the constitutions 
of some families are particularly disposed to disorders of the digestive 
apparatus. We are acquainted with one family in this cit} T , in which 
eight out of ten children, suffered more or less from the disease. Again, 
of these children four have grown up, married, and have children. Two 
of these families have each lost a child from the disease ; in a third, the 
two children of the family have been exceedingly ill with it ; while in the 
fourth, some of the children have been sick, though not to the same de- 
gree. Again, we have attended two children in a family, one not quite two 
years, and the other three months and a half old, who have both been very 
sick with the disease. The elder child was ill the summer before in the 



ANATOMICAL LESIONS AND PATHOLOGY. 383 

same way. The mother of these children was herself very ill with the 
disease on several occasions during her infancy, as was also her brother. 

Anatomical Lesioxs and Pathology. — It will be readily understood 
that it is far from an eas} T task to define precisely what are the essential 
lesions in true cholera infantum, as we have described it. Having been con- 
founded so long with ordinary inflammatory diarrhoea, the lesions usually 
attributed to it are precisely those we have detailed in our article on the 
latter affection. In those cases again where the true choleraic disease 
appears during the course of inflammatory diarrhoea, it is of course diffi- 
cult to determine to which affection the lesions presented after death are 
in reality due. We must, therefore, seek for the true and proper lesions 
of cholera infantum in the comparatively rare cases in which this affec- 
tion has appeared in the midst of good health, and has proved fatal dur- 
ing the acute stage. With this restriction then, it appears that the only 
anatomical changes which can be regarded as constant and essential to 
the disease, are enlargement of the mucous follicles, and to a less degree, 
of the glands of Peyer ; and softening, and in some cases erythematous 
inflammation of the mucous membrane. 

There can be little doubt that the appearances thus indicated, depend 
upon the presence of an early stage of inflammation of the tissues of the 
intestinal walls, and of the mucous follicles. This view is supported by the 
similarity between these lesions and those found in cases of entero-colitis, 
proving fatal during the early stage, as well as by the fact that where 
the child survives the choleraic stage, and ultimately dies after a continu- 
ance of diarrhoea for some days, or even several weeks, the lesions are 
found to have developed into those ordinarily found in primary entero- 
colitis. 

It is, however, necessary to consider briefly what additional element is 
present, in this form of disease, which impresses upon it such peculiar 
and fatal features ; or, in other words, what is the pathology of the col- 
lapse which characterizes cholera infantum. 

It is a matter of much regret, that as yet we are wanting in careful 
microscopical examinations of the condition of the epithelium of the 
mucous membrane, and of the characters of the evacuations. We should 
anticipate, however, from the evident similarity between cholera infantum 
and sporadic cholera, or cholera morbus in the adult, that in the former 
as in the latter disease, such examination would reveal rapid proliferation 
and exfoliation of the cells of the mucous membrane. 

In regard to the explanation of these lesions, we would refer the reader 
to the remarks upon the pathology of entero-colitis, where we have ex- 
pressed our belief that the causes of these affections (heat, noxious ema- 
nations, unwholesome food), act in a complicated manner, by inducing a 
state of malnutrition in which the tissues are prone to undergo inflamma- 
tory changes, by loading the blood with noxious substances, which may 
irritate the glands which excrete them, and finally by interfering with 
digestion, so that the contents of the intestinal canal undergo changes 
which render them highly irritating. 



384 CHOLERA INFANTUM. 

We repeat that we recognize in cholera infantum the presence of the 
general alteration of nutrition, and the change in the entire blood-mass, 
as well as the local irritant action of the morbid contents of the intes- 
tines. But it is in the highest degree interesting and significant of the 
importance of this last element in the causation, that symptoms alto- 
gether indistinguishable from those of cholera collapse, may be produced 
by agencies acting directly and solely upon the coats of the stomach and 
intestines. 

Attention has been lately directed to these analogous conditions by 
Sedgwick, in a highly valuable article, " On some Analogies of Cholera, 
in which suppression of urine is not accompanied by symptoms of ursemic 
poisoning" (Med. Chir. Trans., vol. li, p. 1, 1868), in which he has col- 
lected many such examples. Among the causes which are clearly estab- 
lished as capable of producing such an analogous condition, are poisonous 
doses of corrosive sublimate, arsenic, some of the mineral acids, especially 
nitric acid ; and also of certain drastic purgatives, especially croton oil. 
In these cases the peculiar symptoms produced, which are uniformly 
described by accurate observers as most closely analogous to those of 
cholera collapse, are due exclusively to the direct irritant action of the 
substance upon the gastro-intestinal mucous membrane. 

The same effects have frequently been observed to follow the eating or 
drinking of poisonous animal matters, such as tainted or simply unwhole- 
some meat or fish, and milk which has undergone some injurious, but as 
yet unknown change, decomposing vegetables, and some of the poisonous 
fungi. In this last group of cases, the local irritant action of the sub- 
stances swallowed, must certainly be regarded as the principal cause in 
the production of the symptoms, although it is quite possible that the 
ingestion of such putrid animal or vegetable substances should also cause 
an altered condition of the blood. 

In like manner, there are numerous morbid conditions of the intestines, 
or their peritoneal covering (as perforation with subsequent peritonitis, 
peritonitis from extension of inflammation, intestinal obstruction), which 
may be attended with symptoms closely analogous to those of cholera 
collapse. 

We will also quote from Rilliet and Barthez, the following passage in 
regard to the remarkable memoirs upon Inanition, by Dr. Chossat, of Ge- 
neva, which show the analogy which exists between the results of experi- 
mental inanition and the chief symptoms of cholera infantum. " This 
is seen especially (1.) In the diminution of temperature, which conjoined 
with the loss of weight, is in inanition, as in cholera infantum, one of the 
principal causes of death. (2.) In the stupor which follows the jactitation 
as the temperature falls. (3.) In the colliquative diarrhoea during the last 
few days of life, the severity of which is proportioned to the rapidity of 
the fatal termination, and to the increase of the algidity." 

It is not within the scope of the present work to discuss, critically, the 
various theories which have been advanced to explain the modus ope- 
randi of such causes in producing a state of collapse analogous to that 
of cholera, as well as the pathology of true cholera collapse. 



ANATOMICAL LESIONS AND PATHOLOGY. 385 

It is. however, evident, that the mere drain of fluid from the alimen- 
tary canal, although it undoubtedly has much influence upon the course of 
the disease, cannot be regarded as the efficient cause of collapse, since 
in many cases profound collapse occurs with comparatively scanty dis- 
charges. 

So too we must regard Dr. Johnson's hypothesis (Medico-Chir. Trans., 
vol. li, 1867, p. 103, et seq.), that the symptoms of collapse are due to a 
spasm of the minute branches of the pulmonary artery, caused by the 
specific alteration of the blood in cholera, as based upon insufficient ar- 
guments. Thus, in the first place, we have cited instances above where 
S3'mptoms altogether similar to those of cholera collapse, are produced 
under circumstances in which it is impossible even to suspect the exist- 
ence of a poisoned state of the blood. Again, there is neither any clini- 
cal or anatomical evidence to show that the contraction of the pulmonary 
artery is relatively greater than that of the rest of the arterial system ; 
or again, that such contraction precedes the other signs of collapse. 

In the last edition of this work, we quoted the opinion of Rilliet and 
Barthez in regard to the implication of the sympathetic nervous system 
in cholera infantum, and since that time we have been led to regard this 
more and more strongly as the essential cause of the collapse which char- 
acterizes this and other choleraic conditions. 

The passage extracted from the admirable work of Rilliet and Barthez, 
was as follows : "The disease we have just described is, in our opinion, 
a catarrh which has localized itself upon the digestive tube and the great 
sympathetic nerve. It is, of all forms of the catarrhal affection,, that 
which most clearly justifies the idea of a poisoning. It proves also that 
anatomical differences alone will not suffice to establish a separation be- 
tween the various species of the disease. 

" Its catarrhal nature is demonstrated by the causes, which are those 
of all catarrhs (improper alimentation, epidemic influence, &c.) ; by the 
analogy of the symptoms; b}^ the gradual passage of the mild, into the 
grave forms, through intermediate cases ; and lastly, by the fact that 
simple intestinal catarrh is often but the prodrome of choleriform enter- 
itis. 

" Reasoning from the simple fact that the disease is catarrhal,, we ad- 
mit the existence of a modification of the whole economy,, and of some 
alteration of the blood. 

"A study of the anatomico-pathological descriptions of the disease, and 
especially the observation of cases, demonstrates that the gastro-intes- 
tinal tube of children dying of this affection, may be found in four differ- 
ent conditions : 

" a. Either the stomach is softened without any lesion of the digestive 
tube. 

"6. Or the stomach is softened, at the same time that the mucous mem- 
brane of the intestines and especially its follicular apparatus, is diseased. 

"c. Or the stomach is healthy, whilst the follicular apparatus or the 
mucous membrane are diseased. 

" d. Or, lastly, the gastro-intestinal tube fails to exhibit any lesions 

25 



386 CHOLERA INFANTUM. 

appreciable by our senses in the present state of our knowledge, or it 
presents alterations too insignificant to explain the gravity of the symp- 
toms." 

. . . . " Up to this point the disease resembles all other catarrhs, but 
what gives to it a special type, is the abundance of the serous secretions 
and the disturbance of the great sympathetic nerve. 

"The serous secretion, which seems to be produced by perspiration 
(analogous to that of the respiratory passages and of the skin), rather than 
by a follicular secretion, shows, perhaps, that the elimination of morbid 
matter is accomplished by other organs than the follicles ; and we ought 
perhaps, to see in this a proof that the matters to be eliminated are not 
the same as in simple catarrh. On all these points we are compelled to 
remain in doubt ; we content ourselves with stating the fact. 

" The functional derangements of the trisplanchnic nerve play an im- 
portant part in the disease ; under this point of view it differs from the 
mild form, in which the innervation is normal, and from the cerebral form, 
in which it is especially the cerebro-spinal apparatus that is sympatheti- 
cally affected. The proof of a disturbance of the ganglionic nervous S} r s- 
tem, rests upon the following physiological and nosological considera- 
tions : 

" The disease exists at the age and in the physiological condition (den- 
tition), in which functional derangement of the nervous sj^stem without 
lesions of organs, are most frequent ; it is often complicated with those 
very disorders of the general innervation, as is proved by certain pro- 
found changes in the functions of nutrition, circulation, and calorification, 
which the amount of material waste will not always account for. We oc- 
casionally observe the same symptoms of nervous sideration, and particu- 
larly the extreme smallness of the pulse, and the algid phenomena, to 
arise in certain of the most violent attacks of spontaneous peritonitis. 
Now these phenomena which cannot always be referred to the intensity 
of the pain, and which do not exist in inflammations of the other serous 
membranes, no matter what the rapidity of their course, are only to be 
explained by the fact that the disease, seated in the abdomen, envelops 
the ganglia of the great sympathetic nerve." 

Since the date at which this was written, our knowledge of the func- 
tions of the sympathetic nerve, especially with regard to its power of 
regulating the calibre of the arteries, b}" inducing contraction or allowing 
relaxation of their muscular coat, has been much advanced ; and we are 
fully prepared to understand how the sj^mptoms of cholera collapse might 
be explained upon the supposition of a wide-spread powerful irritation of 
the fibres of the sympathetic nerve, so richly distributed to the coats of 
the alimentary canal, and which have such intimate relations with the 
nervous supply of the whole arterial system, the heart and lungs. 

Thus we can most readily explain in this way, the small, thready pulse ; 
the cold, pale, and shrunken skin ; the asphyxia and coldness of the 
breath; the diminution in the formation of urea and in the secretion of 
urine. 

The above views of the patholog} 7 of choleraic collapse, have been of 






SYMPTOMS. 387 

late ably supported by Sedgwick (loc. cit.), and Dr. Horace Jeaffreson 
(JEdin. Med. Jour., December, 1866, p. 520). 

At the same time, the probability is that the vaso-motor nerves of the 
intestinal walls themselves are paralyzed, from exhaustion of their excita- 
bilit}", so that dilatation of the vessels occurs with profuse discharge of 
serum. 

So far as experimental research can be made available in deciding ques- 
tions involving such deep-seated and delicate parts, the results entirely 
confirm the explanation given above. Thus both Moreau 1 and Asp, 2 have 
found that, after section of the branches of the sympathetic nerve supply- 
ing the intestines, a copious secretion of alkaline serous fluid takes place 
into the bowel. 

Symptoms. — Restricting, as we now do, the term cholera infantum to 
cases which have a truly choleraic character, we shall have a smaller 
ground to go over than we had in our previous editions. 

The invasion of the choleraic symptoms is sudden. The child may 
have been quite well previously, or may have been the subject for an in- 
definite length of time — days or weeks — of simple or inflammatory diar- 
rhoea, when, from exposure to high summer heats (85° to 95° Fahr.) in 
a city, or more rarely, in the country ; from being allowed to take some 
unwholesome article of food ; from the effort of cutting teeth ; or perhaps 
from having been chilled by night air, or by a sudden change of the 
weather from hot to cool ; the choleraic disorder breaks out, with almost 
simultaneous vomiting and purging. The diarrhoea is, from the begin- 
ning, violent. The stools are usually frequent, consisting almost entirely 
of a thin fluid, which runs through the napkins and wets the clothes of 
the child. Sometimes the discharges are not very frequent, but each one 
may be so large as to wet not only the napkins and clothes of the child, 
but to run through to the lap or bed on which the patient lies. The chief 
and important characters of the stools in true cholera infantum, as in 
cholera of the adult, are their fluidity and quantity. These two charac- 
ters, more than the vomiting or the nature of the discharges in any other 
respect, are the special signs of the disease, and by the degree in which 
they are present do we recognize the disease, and usually determine its 
severity. The fluid thus rendered by stool may be of different charac- 
ters. It may be an almost colorless liquid, merely wetting the napkins 
and clothing, as though they had been dipped into a bucket of water, or 
saturated with the pale urine of a healthy infant ; or they may consist of 
the same watery fluid, holding in suspension small and soft flocculi of 
fecal matter of a yellowish or greenish color, or small, detached portions 
of mucus, which are left upon the napkins as the watery fluid drains 
through them. When the stools are of this kind, they are usually almost 
inodorous. In other cases, they are still very watery, but the fluid is 

1 Comp. Kend. de l'Acad. des Sciences, t. lxvi, p. 554, 1868, in Medical Times and 
Gaz., April 11th, 1868, p. 397. 

2 Beobacht. u. Gefassnerven, Ludwig's Arbeiten, 1868, p. 131, Abst. in Jour, of 
Anat. and Phys., November, 1868, p. 211. 



388 CHOLERA INFANTUM. 

yellowish or brownish in color, contains rather a larger amount of thin 
feculent matter, and has a most offensive odor, — an odor which is pecu- 
liar for its extreme fetidity, a feticlity so great that we have known it to 
cause vomiting in those exposed to it, and so adhesive as to render it 
necessary to change at once all the clothing and bed-linen of the child, 
and even then the fetor may cling to the body of the patient after re- 
peated washings. This odor we have seldom met with except in the 
choleraic form of summer diarrhoea. The number of the stools varies 
greatly. We have known as many as twelve to be passed in as many 
hours. In other cases they are not so frequent, but the quantity at each 
time may be so great as to drain the body of its fluids at a more rapid 
rate than many more evacuations of an ordinary size. Eight, twelve, fif- 
teen, or more than twenty stools in twenty-four hours are not rare. In 
one fatal case, in a child between one and two years old, there were be- 
tween twentjr-five and thirty stools during the second night of the attack, 
in a space of twelve hours. 

Simultaneously with, or soon after the diarrhoea sets in, there is vomit- 
ing. The matters vomited consist at first of the ordinary contents of the 
stomach, food, and water. Soon these matters consist of the water or 
medicines that may be taken, and of a serous or sero-mucous fluid 
mixed with small portions of bilious matter. Sometimes they are tinted 
green as so often happens in the gastro-intestinal affections of children. 
The vomiting may or may not be veiy frequent. Sometimes it is one of 
the severest elements of the disease, causing everything taken to be re- 
jected almost as soon as swallowed, or assuming the form of repeated and 
exhausting retching even when the stomach is quite empt}^. In connec- 
tion witjh these. S3 T mptoms there is rapid loss of strength. The child is list- 
less and still between the evacuations and vomiting, or tosses and moans 
with the jactitation of severe illness. The appetite is lost, but thirst 
is extreme, and constitutes one of the marked phenomena of the disease. 
Water and ice are seized upon with the greatest avidity, and taken 
almost incessantly, if allowed, though rejected only a few moments after- 
wards. 

The abdomen is flaccid or retracted, not tender to the touch usually, 
and the walls inelastic, so that they can be readily pinched up into folds. 
The tongue, moist at first, with a thin white fur upon it, becomes pasty 
or dryish after a time, and is sometimes protruded from time to time be- 
tween the lips. 

The pulse runs up from the first, rising soon to 130, 140, and 150, and 
being usually small in volume, whilst the temperature remains for a time 
normal, rises slightly above the natural point, or, in some few cases, the 
skin becomes hot. The urine diminishes in all these cases, and in very 
severe ones, ceases to flow, or flows only in the smallest quantities. As 
in true cholera, the degree of suppression of this function is in propor- 
tion to the severity of the choleraic discharges. The respiration, natural 
at first, soon becomes, if the case goes on unfavorably, irregular, unequal, 
and anxious. The temper is irritable at the beginning, the child being 
restless, peevish, disposed to fret and ciy at the least contradiction or 



SYMPTOMS. 389 

disturbance. The sleep is restless and disturbed, especially at night. 
The child wakes frequently, and almost always with crying. When asleep, 
the eyes are often but half closed, and the brow contracted and frowning. 
The countenance soon becomes anxious and distressed. In sudden and 
severe attacks, it is languid and subdued, pale and contracted. 

If the disease is not soon checked, signs of collapse make their appear- 
ance, and become more and more marked features. The body becomes 
cool and then cold, the pulse grows smaller, thready, and very rapid ; the 
features are drawn ; the nose is sharp and thin ; the eyes shrink within 
the orbits ; the cheeks become sunken ; the patient passes into a still, quiet, 
and drows}' state ; the vomiting may cease, but the diarrhoea usually per- 
sists ; the child falls into a comatose or semi-comatose state, and death 
occurs quietly in this condition, or may be preceded by slight convulsive 
movements. Some very violent cases run their course in a day, a day 
and a half, or two or three claj's. We, ourselves, do not recollect to have 
seen any case terminate sooner than in three days and a half. 

In favorable cases, after one, two, or three days, the diarrhoea ceases 
to be so violent ; the stools grow less frequent, smaller in quantity, thicker 
in consistence, containing a better concocted fecal matter, and regaining 
a more natural odor. The vomiting and thirst gradually subside ; food 
is again taken and retained ; the circulation falls, and the child, though 
weak and thin, and the subject for some days of a simple diarrhoea, may 
regain its health iu great measure, at the end of a week or ten days. 
More frequently, however, the disease assumes the form of a more obsti- 
nate simple or inflammatory diarrhoea, which may last for several weeks, 
to take on again, perhaps, from a recurrence of the exciting causes, the 
choleraic form, or to persist in one of the former shapes until the return 
of cool weather. 

Such is a picture of the disorder to which we think the name of cholera 
infantum ought to be restricted. If physicians could agree to limit the 
title to this true choleraic disease, our mortality returns would soon show 
the comparative frequency of death from this disorder, and from those 
more tedious and chronic diseases which have already been treated of 
under the designation of simple and inflammatory diarrhoea or entero- 
colitis. 

The duration of cholera infantum, as we restrict the term, is seldom 
more than two, three, or four days. It ma} r prove fatal in a much shorter 
time. Dr. Eberle (Dis. of Children, p. 285) says it sometimes runs on 
to a fatal termination in five or six hours. Dr. J. Lewis Smith (op. cit., 
p. 392) reports a case in a child sixteen months old, which ended fatally 
in less than one day; a second, at seven months, after a sickness of about 
one day ; and a third, at twenty months, in thii^-six hours. We do not 
recollect, in our own experience, which has been chiefly in private prac- 
tice, a shorter case than one of three clays and a half. In favorable cases 
the diarrhoea usually persists, as already stated, for several da}'s after the 
disappearance of the choleraic phenomena, and very frequently runs on 
into a simple or inflammatory diarrhoea, which follows the law of those 
disorders. 



390 CHOLERA INFANTUM. 

Diagnosis. — The diagnosis of cholera infantum requires no particular 
elucidation. The season at which it is most prevalent ; the profuse, serous, 
or at least fluid evacuations; the frequent and severe vomiting ; ithe early 
exhaustion of , muscular strength; the rapid pulse, with absence of, or a 
very moderate febrile heat; the threatening or the actual supervention of 
collapse, marked by cool or cold surface, pinched and anxious counte- 
nance, shrivelled skin, sighing or irregular respiration, rapid and feeble 
or extinguished pulse, diminished or suppressed urinary secretion ; with, 
finally, the still and limp body, and drowsy or comatose brain, all mark 
a disorder which is readily recognized after being once seen, or which 
may be distinguished b}^ any intelligent person who has never yet met with 
such a case, if only the progression of the symptoms be carefully inquired 
into, and correlated with the present condition. 

Prognosis. — Cholera infantum, as we restrict the use of the term, is, 
of course, always a dangerous disease. Collapse, which either threatens 
all who are attacked by it, or actually supervenes to a greater or less de- 
gree, is well known by all physicians to be one of the most formidable 
morbid conditions to which the body is liable. The degree of danger in 
any individual case must depend chiefly upon the ability of the physician 
to arrest, and of the patient to resist, this state. The probability of the 
supervention of collapse depends very much upon the hygienic condition 
in which the child is placed, upon the age of the patient, the state of the 
process of dentition, the present state of health, the innate vigor of the 
constitutional force, and also, we msiy say, upon the period of the dis- 
ease and the degree of wisdom with which medical means are applied. 
Children placed in favorable Irygienic conditions in the country, or in 
the healthier parts of cities, in large and well-ventilated rooms, and who 
have been fed upon proper diet, and who have therefore been attacked by 
the disease whilst in previous fair health, are much more apt to escape 
collapse, or to recover from it, after it has made its appearance in a more 
or less marked degree, than those who are placed in conditions the oppo- 
site of those we have enumerated. Early age, recent weaning, improper 
artificial diet, and feeble vital powers from any cause, either inherent or 
acquired, are amongst the most unfavorable prognostics. Still, we should 
never despair until the last moment, since we have seen some most sur- 
prising recoveries from apparently desperate conditions in this disease. 

The prognosis ma} 7 be stated in general terms to be unfavorable in 
proportion to the frequency and violence of the vomiting, the number of 
the stools, the severity of the fever, and the more or less marked charac- 
ter of the collapse. When the discharges consist merely of serous fluid, 
and are copious and frequent ; when they consist of small quantities of 
deep green matter, mixed with much mucus or with blood ; when accom- 
panied by straining ; when they number from fifteen to twenty-five in the 
day ; when they are veiy fetid ; and when, with these symptoms, the ab- 
domen is tense and tympanitic, the countenance pinched, the expression 
languid, the extremities cool, the pulse rapid and small, and the child 
irritable and restless, or, on the other hand, very still and subdued, the 
prognosis is exceedingly bad. If, after the symptoms just enumerated, 



TREATMENT. 



§91 



drowsiness or stupor, and then cbnia, convulsions, rigidity, or paralysis 
make their appearance, there is scarcely a hope left. 

The favorable symptoms in airy case are, diminution of the fever ; equal 
temperature of the whole surface; cessation of vomiting; decrease in the 
number of the stools, and a return to their natural color, consistence, and 
odor ; quiet, tranquil sleep ; return of appetite ; and lastly, a restoration 
of the natural temper and gaj-ety of the child. 

Treatment. — Prophylactic Treatment. — The clanger to which teething 
children are exposed from residence in this city during the hot months of 
the year, is now so well understood that most families who can afford it 
remove to the country during the warm season, and by this course very 
generally avoid the disease. It is undoubtedly the best plan that can be 
adopted, and very commonly succeeds. When this cannot be done, how- 
ever, the prophylactic treatment consists in a most careful attention to 
diet, dress, and exposure to the open air. If possible, the child should 
be kept at the breast until it has passed through its second summer, as 
there is but little danger from the disease after that period. If the wean- 
ing must take place prior to that age, it ought to be accomplished before 
the hot weather begins, as a change from the breast to artificial food 
during the warm season is very apt to bring on the disease. If the child 
is weaned, the diet must be strictly attended to. Up to the age of ten 
months or a year, the food should consist almost wholly of milk contain- 
ing arrowroot, rice, oatmeal, or some farinaceous substance in small quan- 
tity. A little plain chicken or mutton water, with rice boiled in it, or a 
piece of beef or chicken to suck, may be given occasionally, but all vege- 
tables and fruits should be strictly forbidden. After the age of ten 
months, some light soup and small portions of mutton, chicken, or Very 
tender beef, minced very tine, ma}^ be given every day in addition to the 
milk food, which must still form the major part of the child's nutriment. 
Fruit of all kinds, all vegetables except rice and potatoes, and the latter 
are doubtful, ought to be carefully avoided until after the hot season has 
passed entirely away, or until the child has its full set of teeth. We have 
found the food prepared with gelatine, in the manner described at page 
304, to answer better than anything else for a large number of children 
to whom we have prescribed it. 

The dress ought to be arranged according to the heat of the day. It 
is the fashion in this city to keep young children clothed all summer in 
thick flannel jackets, and petticoats, and woollen socks. This is certainly 
too much for the hot days which so frequently occur in July, August, and 
early in September, and is often, we believe, very injurious. A light gauze 
flannel shirt is the only woollen garment that need be worn during the 
warm season. On hot da} r s a child should have only this, a muslin petti- 
coat and frock, and the lightest possible socks, or none at all. If, as con- 
stantly happens in our climate, a cool day comes, there should be added 
to these a light flannel petticoat. 

It is of the utmost importance that children should pass as large a por- 
tion of the day as possible in the open air. In the country this is easily 
managed, and parents almost always contrive to accomplish it ; but in a 



392 CHOLERA INFANTUM. 

city, many people seem to think it of less importance, or their servants 
are occupied with other things, and it is neglected. It is nevertheless a 
matter of the greatest consequence ; the child ought to be kept in the air 
by the nurse for several hours in the morning and evening, either in the 
garden attached to the house, if there be oue, at the front door, walking 
in shady streets or public squares, or, better still, making short excursions 
into the neighboring country, taking care, however, to avoid the intense 
heat of the sun during the middle of the da}\ 

We believe that with constant and wise attention to these points, viz., 
diet, dress, exposure to the air, and exercise, much may be done towards 
preventing the disease even in families obliged to remain in the city dur- 
ing the summer. 

As stated in the account of the s} r mptoms, the choleraic disease often 
supervenes in children who have already been the subjects of simple or 
inflammatory diarrhoea. When, therefore, a child in the city has diar- 
rhoea, if it do not } T ield readily to treatment, and especially if the stools 
begin to be thin and watery, with an}^ marked tendency to exhaustion, it 
ought to be regarded as being threatened with cholera. In such an event, 
the best prophylaxis in the world is instant removal to some high country 
locality or the seaside. 

Treatment. — Regarding this disease as a truly choleraic one, we shall 
follow, in the consideration of its treatment, the plan adopted b} r some 
of the more recent writers on Asiatic cholera ; and shall accordingly divide 
our discussion of this subject into the treatment appropriate for the three 
stages of evacuation, collapse, aud reaction. 

Every young child who is attacked with diarrhoea, whether simple or 
inflammatoiy, in the summer season, ought to be regarded as liable to 
cholera, and should be carefully watched to prevent the development of 
this disease. For the proper treatment of such conditions, the reader is 
referred to the article on those affections. 

Should a child, either previously well, or the subject of diarrhoea of 
the ordinaiy form, be attacked with, sudden, profuse, frequent, and watery 
discharges, and especially, should these be associated with vomiting, with 
spasmodic intestinal pain, and with airy appearance of general exhaus- 
tion, it ought to be presumed to be in the early or evacuation stage of 
cholera infantum, or in what is the analogue of the evacuation stage of 
epidemic cholera. Under these circumstances, it has been a prevalent 
practice here to give a cathartic, castor oil, calomel, or rhubarb. We 
think the practice wrong, unless there be positive evidence that the 
attack has followed directly upon the use of some unwholesome article of 
diet. If it be found that the child has certainly eaten some such food, 
green apples, currants, gooseberries, or articles of this kind, and that 
these have not come awa}^ in the discharges, it is right to give first a 
moderate purgative. We prefer castor oil or syrup of rhubarb, half a 
teaspoonful of the former, or a teaspoonful of the latter, with two drops 
of laudanum at the age of one y ear, or a teaspoonful of castor oil, or two 
of the syrup of rhubarb, with four drops of laudanum at two or three 
years of age. Two hours after this dose, if the stools continue frequent 



TREATMENT. 393 

and watery, we use the chalk mixture, with tincture of krameria and 
laudanum or paregoric (a teaspoonful of the chalk mixture with ten to 
fifteen drops of the krameria, and one drop of laudanum, or five of pare- 
goric) every two hours at the age of one year. Thirty drops of the syrup 
of nutgalls (see article on entero-colitls), with an opiate every two hours, 
is often very useful. We believe that the great object is to arrest the 
watery discharges by stool. If the above means fail, laudanum may be 
given by injection, and two drops at one 3 T ear, and double the dose at two 
years, every two or three hours, may be tried in addition to the above 
treatment. The quantity of opium must depend on its effects. Children, 
like adults, bear very different amounts. As soon as positive drowsiness 
appears, or the pupils become contracted much below their natural size, 
the doses must be suspended or diminished, or the intervals between 
them lengthened. Of course, if the stools lessen in frequenc}^, quantity, 
or fluidity, the same reduction in the amount of the opium ought to be 
made. 

When vomiting is severe and frequent, and the above remedies are re- 
jected, we ma3 r use the one proposed in the article on inflammatory diar- 
rhoea, consisting of solution of morphia, dilute sulphuric acid, and cura- 
coa cordial. This, or some similar remedy, is at times very successful. 
It is nineteen years since one of us saw a child nine months old, in deep 
collapse from a most violent attack of cholera infantum, who rejected its 
mother's milk as though it had been tartar emetic, whose stomach was 
only made worse by calomel, but who began to improve very soon upon 
doses consisting of two drops of aromatic sulphuric acid, and five drops 
of solution of morphia, in a teaspoonful of iced-water, ever}^ hour. Since 
then we have frequently used the mixture above recommended in such 
cases, and we think, on the whole, with more control over the vomiting 
than anything else we have tried. 

The experience gained by careful and lengthened observation in the 
treatment of the evacuation stage of Asiatic cholera, may well be applied 
to the affection under consideration, so much alike are the3 T . Dr. Good- 
eve (loc. cit., p. ITT) gives first a full dose of opium (he saj's that calomel 
was generally combined with it in India, and though he does not "know 
that the calomel does good, it does no harm"), to an adult two grains, 
and half an hour afterwards he begins with an astringent, in his own 
practice, usually the following mixture : 

R. — Plurabi Acetat., gr. xxx. 

Acid Acet., n^x. 

Aq. Destillat, fgvj.— M. et ft. sol. 

One ounce or half an ounce every half hour or hour. 

At the end of an hour from the administration of the first dose of 
opium, if the purging persisted, he gave one grain of opium and con- 
tinued the astringent. A small teaspoonful, or two-thirds of an ordinary 
teaspoonful of this solution would contain about half a grain of the ace- 
tate of lead, and this might safely be given to a child a year old for 
several doses. We have not used this remedy ourselves, but it comes 



394 CHOLERA INFANTUM. 

from a source which commends itself to us, and we shall not hesitate to 
use it when the occasion presents itself. As soon as the frequency of the 
discharges is arrested, the doses should be given at longer intervals, and 
when the peculiar serous character of the stools has disappeared, this 
remedy ought to be suspended, and some more simple one substituted, 
in order to avoid the possibility of producing the toxic action of lead. 

If, in spite of the treatment, the stage of collapse should set in, other 
methods of treatment must be adopted. Here the stools are usually in 
great measure arrested, or they are few in number and small in amount. 
The object to be sought after is to produce reaction, or rather to favor 
the efforts of nature to bring about this change. It is now generally ac- 
knowledged by men of large experience, that the old plan of pouring in 
large doses of opium and alcohol is a great mistake. But little is ab- 
sorbed by the stomach whilst the body is in this condition, and not 
unfrequently the patient is injured, perhaps fatally, by the sudden ab- 
sorption of these substances, when the stomach begins to act after reac- 
tion has taken place. The opium may cause dangerous or fatal stupor, 
or may increase or keep up the tendency to suspension of the urinary 
function, and thus promote one of the great dangers of the disease, 
ursemic intoxication. The alcohol, if it has been used in large quantities, 
would also tend to clog the nervous centres, to cause gastric or gastro- 
intestinal catarrh, and to heighten bej-ond a safe point the febrile move- 
ment which is so apt to accompany the reaction stage. Opium, therefore, 
should be avoided during collapse, or given only in the smallest doses. 
Alcohol, though it should never be given in large doses, and recklessly, 
as has so often been done, may be used in small quantities, especially if 
it be found by close watching, that it promotes the force and volume of 
the pulse. Ten or fifteen drop doses of old and delicate brandy, in a 
teaspoonful or tablespoonful of ice-water, may be given every hour or 
two hours, at one 3<ear of age. During collapse the stomach is still often 
very irritable, and yet the thirst continues intense. We are glad to find 
that such men as Drs. Maclean and Goodeve recommend the free use of 
ice and water under these circurnstances. Our own practice, for years 
past, has been to allow ice and cold water, almost without limit, to chil- 
dren in this condition, and we are much pleased to know that such, too, 
is the practice of these gentlemen. We never could understand the wis- 
dom of refusing water to patients who were suffering the horrid thirst 
produced by the immense losses of the water of the bod} 7 hy serous purg- 
ing. The degree of thirst for water (a natural and not a secondaiy dis- 
eased instinct, like that of the drunkard for alcohol) must be the safest 
guide we can have as to the need of the body for water, and as such, it 
ought always, it seems to us, to be gratified, unless under very rare and 
most peculiar conditions. We give water and ice, even though the child 
vomits from time to time, believing and hoping that some will be ab- 
sorbed to take the place in the tissues of that which has been drained off 
through the intestines. This point in the treatment we regard as so im- 
portant, and one, we think, so much misunderstood by the public and b} r 
some medical men, that we make the following quotation from a note of 



TREATMENT. 395 

Professor Maclean's to Dr. Aitken (Aitken's Practice, vol. i, foot-note, 
page 663): "Urgent thirst is one of the most distressing symptoms in 
cholera ; there is incessant craving for cold water, doubtless instinctive, 
to correct the inspissated condition of the blood, due to the so rapid 
escape of the liquor sanguinis. It was formerly the practice to withhold 
water — a practice as cruel as it is mischievous. Water in abundance, 
pure and cold, should be given to the patient, and he should be encour- 
aged to drink it, even should a large portion of it be rejected by the 
stomach ; and when the purging has ceased, some may with advantage 
be thrown into the bowel from time to time." The use of water by ene- 
ma, when the diarrhoea is checked, is a point which ought not to be neg- 
lected, especially if the stomach continues weak and irritable. A gill of 
tepid water may be used at a time, thrown slowly and gently into the 
bowel, in the case of a child one or two years old. If this is retained 
well, the same quantity may be repeated in one or two hours. 

Whilst the collapse lasts, but little food can be taken. It is seldom 
retained if used in any quantity, and the stomach has lost, in great 
measure, its digestive power. The only food we have found at all avail- 
able has been thin chicken tea, Liebig's cold extract of beef, or weak wine- 
whey, given in two or three teaspoonful doses, eveiy half hour or hour. 
It is worse than useless to attempt more than this, as not only is it not 
retained, but it evidently tends to keep up the nausea and vomiting, and 
thus retard the natural effort at reaction. As« to remedies in this con- 
dition, we doubt whether anything better can be done than to use water, 
as just advised, and small doses of brandy, and, if they can be borne, 
small quantities of the liquor ammonise acetatis, ten to twenty drops, in 
cold water, every hour, at one year of age. There is, however, a remedy 
which has obtained a great reputation amongst the English army sur- 
geons in India, for the promotion of reaction in the collapse stage of 
epidemic cholera, which we have used ourselves with advantage in adults, 
but not in children, though we propose trying it when we next have a 
good opportunity. It is spoken highly of by Dr. Maclean. The formula 
is as follows : 

]£. — 01. Anisi, 01. Cajeput, 01. Juniper, aa, . . fgss. 

-^Ether, fg ss . 

Liq. Acid. Halleri, f gss. 

Tinct. Cinnamom., fllj- — M. 

The dose for an adult is ten drops every quarter of an hour, in a tablespoonful of 
water. 

An opiate may be given with the first and second doses, but should not 
be continued, for the reasons already given. The liq. acid. Halleri con- 
sists of one part of concentrated sulphuric acid to three parts of rectified 
spirit. The dose of this mixture for a child a year old, ought, we think, 
to be about one or two drops in a teaspoonful of w r ater, given, as above 
stated, every quarter of an hour. So much is this valued in India, accord- 
ing to Dr. Maclean, that it is always ordered to be kept in store in the 
" medical field companion" of armies on the march. 

It must not be supposed that all children seized with choleraic diarrhoea 



396 CHOLERA INFANTUM. 

are necessarily to pass through the collapse stage in all its terrors. On 
the contrary, many, when judiciously treated early in the disorder, escape 
collapse altogether, and yet they have had none the less the true choleraic 
disease. Others suffer more profuse and exhausting losses of water by 
the discharges, or their yital power of resisting disease is less, and they 
pass into more or less deep collapse ; or hang, as we haye seen them, on 
the very edge of that condition, for one or two da} T s, and then emerge 
from the danger, without having done more than cause the experienced 
physician the grave anxiety which such suspense must and ought to 
create. During these doubtful moments of the attack, the child should 
be kept as quiet and still as possible. He should be made to lie in a 
constantly horizontal position, on a smooth and easy mattress, in the 
crib, or on a large and roomy bed, and as little as may be on the lap, 
which is uneven and unsteady, and which must give his weak and ex- 
hausted muscles more work to do than the}' would have on the more solid 
and even bed. If, however, the nature of the child be such that he clings 
to the mother's or nurse's lap as his only safety, or if he have been taught 
(a most ill-judged lesson) to prefer the lap to any other position, we must 
yield to him, rather than cause fretting or unhappiness, when his very 
life may hang upon the avoidance of all disturbing influences. In this 
case, it is well to place him upon as firm a pillow as can be found, and 
let him be held on this in the lap. It is important to move him, when 
this becomes necessar}^, as slowly and gently as possible, always keeping 
the bocly on a horizontal plane, to avoid the tendency to the S3 T ncopal 
state, which sudden movements, and especially the sitting or erect posi- 
tion, are apt to produce. When the tendency to cooling of the body 
shows itself, and this is usually first noticeable in the hands and feet, ears 
and nose, he should be kept wrapped in warm, dry, and soft flannels or 
blankets. Flannels heated at the fire, thus supplying dry artificial heat, 
are of great use here. Bottles or tins filled with hot water, ought to be 
placed at the feet, under the blanket. A warm, soft, and light poultice 
of Indian meal or flaxseed, with a little mustard incorporated with it, 
may be placed over the abdomen, or three or four thicknesses of flannel? 
wrung out of hot water and whiske} T , may be laid over the lowest part of 
the thorax and over the abdomen, and covered with oiled silk, to retain 
their heat and prevent the wetting of the clothes. Whilst artificial heat 
is thus made use of, fresh air must not be excluded. On the contrary, as 
these cases almost always occur in the hottest summer weather, the 
largest supply of fresh air that can be obtained must be admitted. Warm 
baths, which were proper and useful during the early stage, especially 
when fever was present, we have not found useful in these cases. The 
fatigue and irritation caused by the disturbance of undressing and dress- 
ing the child, have seemed to us to do more harm than any good derived 
from the heat of the water compensated for. 

When the case takes a favorable turn, and the reaction stage begins, it 
is usually best to do nothing more than supply food and water care- 
fully, and keep the body quiet and tranquil. The food ma}^ be cautiously 
and slowly increased in quantity, if the stomach has become settled. 



TREATMENT. 397 

Tablespponfuls of thin chicken-tea, just flavored with salt, or of Liebig's 
cold extract of beef, or of light beef-tea, or of a mixture of wine-whey 
with two or three parts of thin arrowroot decoction (a teaspoonful to a 
piut), may be given every half hour or hour. If these are retained seve- 
ral times, and the child shows some little anxiety for food, the same 
materials may be given in wineglassful quantities. At the same time, 
water and ice ought to be allowed from time to time, as the thirst may 
call for them. On the second or third clay of the reaction, we may give, 
if the child shows a desire for it, a little milk and water and lime-water, 
one part of milk to one or two of water, with one of lime-water, com- 
mencing with not more than two or three ounces of the mixture at each 
feeding. The milk ought certainly to be very much diluted for the first 
three or four days after it is allowed. When the child has been carried 
thus far safely, we may gradually return to its former habits of feeding, 
allowing meat to suck, a little bread, and so on, if it is old enough for 
such habits. 

As to drugs during the reaction stage, they are not necessary if every- 
thing goes on well. If, however, the fever run high, we msiy use small 
closes of the spirit of nitrous ether, as ten drops, in iced-water, every two 
hours at one year, or twenty drops of the solution of acetate of ammonia, 
in the same manner, at the same age. If, as often happens, the urinary 
secretion remains scanty, water, in such quantities as the stomach takes 
willingly, makes probablv the best diuretic ; or we may use the spirit of 
nitrous ether, as just recommended, with a grain of acetate of potash 
and half a drop to a drop of tincture of digitalis, every two hours, for a 
day or two. 

When reaction is thus successfully brought about, the child may either 
improve rapidly and regain its previous health, or simple or inflammatory 
diarrhoea may set in, and pursue the usual course of those disorders. In 
the latter event, the child, if the attacks of cholera have occurred in the 
city, ought certainly to be removed to the country if possible, since it is 
only too apt to have a recurrence of the choleraic disease if kept in town, 
or to suffer, at least, a tedious and more or less dangerous attack of the 
simpler form of diarrhoea. For the proper treatment of either of these 
sequences to cholera, the reader is referred to the articles on those dis- 
eases, with the warning, however, that all such patients ought to be treated 
with every minute care as to lrvgienic and therapeutic measures that ex- 
perience and art have taught us, since the health has been so rudely shaken 
by the sickness already endured. 

We have now laid before the reader, to the best of our ability, what we 
think is the best method of treating cholera in children ; but, before quit- 
ting the subject entirety, we wish to make a few remarks upon points not 
referred to in the above account. 

Attention to the state of the gums should never be neglected in teeth- 
ing children. Our experience leads us to believe most implicitly that the 
process of dentition, or at least that and other concomitant constitutional 
conditions, are constant predisposing causes of gastro-intestinal disorders 
in early life, and that the active hyperannic state, or positive acute in- 



398 CHOLERA INFANTUM. 

flammatory condition, which often attends upon the near approach of 
teeth to the surface of the gurn, may become an exciting cause of acute 
digestive diseases, such as cholera. We think it is always well, there- 
fore, to examine into the state of the mouth in a choleraic child as in 
other infantile disorders ; and if the teeth are felt distinctly through the 
gums, and the gums be found swollen, tense,«hot, and highly vascular, to 
cut them freely once. If, on the contrar} T , the gums are firm, not hot, not 
redder than usual, and the edges of the teeth cannot be felt, it is foolish 
meddlesomeness to cut them. 

Baths. — In the early stage of cholera, before collapse has begun, and 
whilst the child is still reasonably strong, and particularly when there is 
marked febrile heat and dryness of the body, we think that the use of the 
warm or hot bath, or of sponging with hot water and spirit, are excellent 
measures. The bath may be used twice, or even three times a day if the 
child does not resist and scream. The temperature should be 95° to 98°, 
and the child may be kept in the water from five to ten minutes. It is an 
excellent plan to wrap the child, directly on lifting it from the bath, in a 
heated muslin sheet, and. to apply over this a blanket, and keep it thus 
enveloped on the lap for half an hour or more if it is comfortable and dis- 
posed to rest. If the child be somewhat weak, whiske}^, added to the 
water, renders the bath more useful and safe. When the use of a bath 
alarms or annoys so as to cause violent agitation, it is best to substitute 
sponging with hot water and whiskey or vinegar, under a light blanket, 
two or three times a da}^. 

Antiphlogistics. — It may appear to many, in these modern times, a 
mere waste of words for us to state that we are opposed to bloodletting 
in any form or at any stage of cholera infantum. But if any such will 
take the trouble to look over the works of writers of ten and twenty years 
back, he will find reason to think that if this be our opinion, it ought to 
be expressed. When one of ourselves began to practice, in 1841, it was 
quite the custom to take blood for the nervous s} T mptoms which are pres- 
ent in the early stage, and still more for the comatose phenomena at the 
close. This was done on the theory that these symptoms were the result 
of congestion or inflammation of the brain, whereas now they are looked 
upon as the results of exhaustion, of the altered conditions of the blood, 
or of uraemia. 

Calomel. — The opinion was expressed in the last edition of this work, 
that the doses of calomel usually recommended were too large for young 
children, and were apt to aggravate the existing irritation of the digestive 
mucous membrane ; and that such doses of a remedy acknowledged to be 
a powerful sedative, could not be proper in a disease which constantly 
tended towards exhaustion and collapse. It was also stated that the 
small doses which we did recommend had been declared by some critics 
to be entirely too small, and that to this we could only reply that the 
larger and more careful, and, we hoped, the wiser our observation had 
been in the last few }*ears, the more thoroughly convinced were we that 
the larger doses, such as were formerly recommended and used by nearly 
all writers and practitioners, were not only unnecessarily large, but most 



DYSENTERY. 399 

seriously objectionable. We went on to say that the indiscriminate use 
of this remedy, in nearly all cases of the gastro-intestinal diseases of 
childhood became with some, we believed, a mere routine habit, — that 
they never tried what might be accomplished without it, but went on 
pushing the drug in constant doses, when the case, if trusted to simpler 
means, or even left to the efforts of nature, would often do much better, 
we had learned to believe, than when these delicate organs were made 
the receptacle of doses that could not but tend to keep up the nausea, and 
vomiting, and diarrhoea, which form so important a part of the morbid 
phenomena. The experience we have had since that time has but con- 
firmed us in these opinions. Indeed we have so often been disappointed 
in obtaining any good effects from this drug, and have so often had reason 
to think that, instead of allay ing.nausea and vomiting, it increased them, 
and added to the exhaustion which is one of the dangers alwa^ys to be 
contended against, that we have virtually abandoned it. We will add 
that the conclusions reached by the Edinburgh Committee of the British 
Medical Association as to the want of power of mercury to increase the 
flow of bile from the liver, which has been the, great theoretic argument 
for its use in most of the gastro-intestinal diseases of children, have 
tended to confirm our doubts as to its utility in cholera. Not that we 
think that conclusions reached b} r experiments on animals should weigh 
against the careful experience of competent medical men, but when they 
come to confirm doubts raised in ourselves by actual observation of the 
sick, we cannot but take them as confirmatory evidence of the correctness 
of these doubts. 






AKTICLE IV. 

DYSENTERY. 

It seems to us unnecessary to make more than a few remarks on 
dysentery, since we have already spoken of the morbid conditions of the 
large intestine, in our article on entero-colitis. D3^sentery, however, dif- 
fers from this latter affection by the fact that it frequently occurs in an 
epidemic form, and that there is a tendency to more rapid and extensive 
ulceration of the mucous membrane of the rectum and colon. It is an 
acute febrile disease, characterized by frequent evacuations, attended 
with more or less severe pain and straining, and consisting of muco- 
sanguinolent or sanguineous substances, which are due to ulcerative in- 
flammation of the rectum and colon. 

The causes of dysentery are but little understood, beyond the mere 
facts that it occurs as an endemic in some regions of country, and as an 
epidemic over large districts. It is frequent, also, as a sporadic disease, and 
in this form seems to depend upon the same causes as those already cited 
as productive of entero-colitis. Like cholera infantum, it appears to be 
more common in boys than girls, since of 39 cases of which we have kept 



400 DYSENTERY. 

notes, ill winch the sex is mentioned, 27 occurred in bo3 T s, and only 12 
in girls. It is most frequent in the second and third years of life. Of 
38 cases in which the age was noted, 1 occurred in the first year of life, 
15 in the second, 1 in the third, 3 in fourth, 3 in the fifth, 1 in the sixth, 
3 in the seventh, 3 in the eighth, and only 2 from the eighth to the end 
of the eleventh }^ear. It may be either idiopathic or secondary. As a 
secondary affection it is most apt to follow measles and variola. We have 
often known d3 T senteric stools to occur in the course of cholera infantum, 
and in a considerable number of cases such as we have described under 
the title of entero-colitis. 

The anatomical lesions are confined chiefly to the large intestine, and 
are the same as those described under the head of entero-colitis, except 
that they are of a graver character. The mucous membrane is commonly 
found thickened, swelled, red, and softened; the submucous tissue some- 
times presents ecclryniosed paints ; the follicles are often diseased, their 
orifices being enlarged and ulcerated, as described under entero-colitis. 
In grave cases, particularly those occurring under an epidemic influence, 
there are usually more or^less extensive ulcerations, which ma} T implicate 
only the mucous, or extend to the muscular or even peritoneal coat. In 
such instances, pseudo-membranous exudations are often formed, some- 
times in large quantity, and often covering the ulcerations. The intes- 
tine contains sanguinolent mucus, or at times a brownish or greenish 
material, which is evidently the result of a gangrenous condition of the 
mucous membrane, pus, and lastly false membranes. In some rare cases, 
perforation has been known to take place. 

Symptoms. — The symptoms are much the same as those already de- 
scribed as existing in entero-colitis, excepting that the local symptoms 
are more severe, and the presence of blood in the stools constant. The 
disease often begins as a diarrhoea. The stools at first contain feculent 
materials, but after a time become very thin, small in quantity, and con- 
sist chiefly of mucus mixed with blood. The blood may be black and in 
considerable quantity, or of a dark rosy red color, or like the washings 
of flesh; it is mixed with greenish or 3 T ellowish substances, whitish mucus, 
fragments of false membrane, or purulent fluid. In young children there 
is evidently pain, from the restlessness, moving of the limbs, and crying 
about the time of the evacuations, while in those who are older, there is 
true tenesmus, like that observed in adults, and severe pain in the anus. 
The number of stools varies according to the severity of the case. There 
ma} r be only four, eight, or ten in the day, or many more. We have quite 
frequently known as many as 30 and 40 to be voided in the twenty-four 
hours, and in fatal cases, the dejections sometimes number three or four 
in an hour, while between the discharges the child often suffers from most 
violent and painful tenesmus. 

The abdomen is generally distended, tympanitic, warmer than natural, 
and painful. 

In mild cases there is usually no fever, or very little, while in severe 
attacks, there is high fever during the first few days, marked Iry frequent 
pulse, hot dry skin, followed after a time, unless a favorable change takes 






TREATMENT. 401 

place, by coolness of the surface, contraction of the countenance, hollow, 
sunken expression of the eye, rapid emaciation, and death. 

It is useless to give a longer detail of the symptoms, as they are the 
same as those already described in the article on entero-colitis. 

The diagnosis presents no difficulties. The frequency of the discharges, 
the pain in the course of the colon and in the anus, the tenesmus, the 
character of the evacuations, and the febrile reaction, all make the dis- 
ease easy of recognition. 

The prognosis is favorable in mild cases, unattended with much fever, 
or very frequent discharges. When, on the contrary, there is violent 
fever in the beginning, followed by disposition to coolness and collapse ; 
when the stools are exceedingly frequent, and attended with severe pain 
and almost constant straining; and when they consist of nothing but 
mucus, mixed with considerable quantities of blood, or with pus or false 
membranes, the prognosis is very unfavorable. Of 36 cases, the termina- 
tion of which we have recorded, 4 proved fatal. 

Treatment. — The treatment of dysentery in children is often very 
unsatisfactory. The mere variet} T of the remedies recommended by dif- 
ferent writers and practitioners marks the uncertainty of the effects ob- 
tained from drugs. Mild cases so generally get well under an y treatment 
that all methods have had their supporters and advocates, while grave 
cases, and especially those occurring under the influence of severe epi- 
demic visitations, are so difficult of treatment, and often so little under 
the evident control of medical means, as to leave the careful observer in 
great doubt as to what he ought to set down as the evident result of his 
own interference in the case, and what as the results of the efforts of nature 
to cure the disease. 

Mild cases of the disease, in which the fever is not very high, the num- 
ber of stools not great, and the pain and distress moderate, require little 
else than rest in bed, a light and unirritating diet, and the use of opium 
in small quantities either internally or by injection. When there is rea- 
son to suspect the presence of unwholesome food in the stomach, or of 
unhealthy secretions in the intestines, it is necessary to give in the begin- 
ning small doses of some mild cathartic. The one generally preferred is 
castor oil, which may be given either simple, in the dose of a small tea- 
spoonful containing one to four drops of laudanum according to the age, 
or in the form of emulsion. The latter is the mode of employing it usually 
chosen. A drachm of oil should be rubbed up with a scruple of gum, 
a little sugar, from two to eight drops of laudanum according to the age 
of the child, and seven drachms of some aromatic water. The dose is a 
teaspoonful every three or four hours. If the case continue to improve 
under the emulsion, it may be continued for a couple of days, but should 
the stools become more and more frequent, and the pain and tenesmus 
increase, it must be suspended after one or two days, and laudanum 
enemata, with or without the internal use of absorbents and astringents, 
substituted. The injections ought to consist of four or five drops of 
laudanum at two years of age, and of ten drops at five or six years, sus- 
pended in from half an ounce to an ounce of some mucilage, or thin 

26 



402 DYSENTEBY. 

farinaceous fluid, or simply mixed in a tablespoonful of tepid water, 
which is perhaps the best plan of all. The injections may be given every 
four or six hours if necessaiy, or they may be made use of only at night, 
while small doses of Dover's powder are administered every three or four 
hours through the day. 

The diet in these cases should consist of arrowroot, sago, tapioca, or 
some such food, made into thin pap with milk and water ; and the quan- 
tity allowed ought to be very moderate. Rest in bed, in the cradle, or 
in the lap, is very important. The child ought not to be allowed to run 
about, or use exertion of any kind. 

Where the pain is severe and the fever high, and where there is a good 
deal of soreness in the abdomen, depletion ma}?- with propriety be resorted 
to, but alwaj'S with moderation and prudence. A few leeches applied 
around the margin of the anus, or to the surface of the abdomen, often 
prove of great service in relieving pain and tenesmus. An occasional 
warm bath is very soothing and useful. 

In very severe cases of dysentery the treatment is, as above stated, 
difficult and uncertain, owing to the dangerous character of the disease, 
and to the fact that so many different methods have been recommended 
by different writers. 

In the early stage of a severe case, whilst the febrile reaction is high 
and the strength of the patient still unsubdued, depletion by leeches in 
young children and by venesection in older ones, is strongly approved of 
by many able practitioners. For our own part we have not resorted to 
it as a general rule, from the fact that we have so often found the strength 
of the child to fail rapidly under the disease itself. In a few of our cases, 
however, leeching around the anus has been followed by manifest benefit. 
The remedies most commonly depended upon are castor oil, in emulsion 
with laudanum, mercury, sugar of lead, opium, nitrate of silver, spirit of 
turpentine, and astringents. The castor oil emulsion, prepared as men- 
tioned above, is useful in the early part of the attack, but ceases to be so, 
according to our experience, after the first twentj-four or forty-eight 
hours. From mercury we have not ourselves obtained any very positive 
benefit, though, in combination with opium and ipecacuanha in small 
doses, it is much thought of by many excellent authorities. The only 
remedy which is used by all, though it is rarely given alone, is opium, 
and the very fact that it is so universally eniploj T ed points it out as one 
of the most reliable and valuable means we have at our command. It is 
certainly the one upon which we most depend ourselves. It maj^ be given 
either alone or in connection with other substances. Where injections 
can be retained it is best given in that way. About five drops of lauda- 
num at two years of age, or ten drops at four or five years, ma}^ be given 
in a tablespoonful of any bland vehicle every four hours. When the rec- 
tum rejects the enema as soon as administered, the opium should be given 
either by the mouth, in the form of laudanum or solution of morphia, or 
in that of Dover's powder ; or in the form of suppository. We should 
indeed strongly recommend the administration of opium in this latter 
form in such cases, since we unquestionably obtain a certain beneficial 



TREATMENT. 403 

local action, in addition to its constitutional effect through its absorption. 
The amount of opium should be about the one- eighth of a grain at two 
years of age, which should be incorporated with butter of cocoa, a most 
bland and soothing substance, which dissolves readily at the temperature 
of the bod}'. When made of this substance, and of proper shape and suf- 
ficiently small, the suppository can be introduced without pain, and will 
usually be retained. The} T should of course be repeated at intervals, de- 
pending upon the effect produced. Opium is almost always emplo3 T ed in 
connection with some other remedy, and particularly with calomel or ace- 
tate of lead. The dose of calomel is from a sixth to half a grain, or, as 
used by some practitioners, a grain, with a twelfth of a grain of opium, or 
half a grain or a grain of Dover's powder, every three or four hours, for 
children two or three years of age. The acetate of lead is more relied 
upon and has probably higher testimony in its favor than calomel. We 
have ourselves obtained excellent effects from it in some instances. The 
dose is from half a grain to a grain every two or three hours at two and 
three 3 T ears of age. 

There are two other remedies not yet mentioned, which have been of 
more positive efficacy in our own practice than any others, with the ex- 
ception of opium. These are the nitrate of silver and the solution of the 
nitrate of iron. The former we have used both internally and by injec- 
tion, the latter only by injection. For an account of the mode in which 
these remedies are employed by different authorities, the reader is referred 
to the remarks on chronic entero-colitis. We have employed nitrate of 
silver in 14 cases of dysentery. These were all severe attacks, and some 
of them most violent. Of the 14 cases, three died. The remedy was 
given by the mouth alone in T cases, b}^ injection alone in 5, and by the 
mouth and by injection both in 2. It has proved most beneficial in its 
effects, in our hands, when given by the mouth, though its influence over 
the disease has alwaj^s been less immediate than when used by injection, 
but it has been more permanent. The dose in which we have used it 
has varied with the age of the child, and with the severity of the symp- 
toms. For children two years old, we have usually employed from one 
grain to one and a half grains, and for those of five or six years or up- 
wards, two grains dissolved in two ounces of a vehicle, consisting of an 
ounce each of syrup of gum arabic and distilled water. The dose is a 
teaspoonful every two or three hours. It is well, as a general rule, to 
add from four to sixteen drops of laudanum., according to the age of the 
subject, to the mixture. For use by injection we have commonly em- 
ployed for each enema two grains for young children, and four grains for 
older ones, dissolved in four ounces of distilled water. The injections 
are to be repeated twice or three times a day. After the nitrate of silver 
enema has come away, it is a good plan to throw into the bowel a lauda- 
num and starch injection. 

We have made use of the solution of nitrate of iron, to which allusion, 
was made above, only as an injection in acute dysentery. We have em- 
ployed it in eight cases, and are quite sure that it was of essential service 
in six, while in two it appeared to irritate, probably because the quantity 



404 DISEASES OF THE CCECUM AND APPENDIX C(ECI. 

given was too large. Our mode of applying it is to mix from ten to twelve 
drops in four ounces of tepid water for each injection. The injections 
were given twice or three times a day, and they were followed, as soon as 
they had returned, b}^ a laudanum injection. On two occasions, the 
nitrate of iron injection remained in the bowel for several hours before 
being rejected, and thus restrained for that time the stools, which had 
previously been very frequent, and attended with much tenesmus. 

When the stools continue very frequent in spite of the use of opium in 
some of its many shapes, when sugar of lead and nitrate of silver have 
been emploj^ed without controlling the frequencj' of the discharges, we 
have sometimes found the mixture of aromatic sulphuric acid, laudanum, 
and syrup of rhatany, before recommended, very beneficial. When the 
stools, in addition to their cbvsenteric characters, have been watery, and 
greenish in color, the chalk mixture, with laudanum and tincture of 
rhatany, kino, or catechu, repeated eveiy two hours, with occasional lau- 
danum enemata, has been very useful. 

The hygienic management of dysentery should be precisely the same as 
that which was suggested as proper for entero-colitis. 



AKTICLE Y. 

DISEASES OF THE COECTJM AND APPEXDIX COZCI — TYPHLITIS AND 
PERITYPHLITIS. 

Synonymes; Definition. — The diseases of the coecum and of its vermi- 
form appendix are so important and frequent, and present so many 
peculiarities as to demand a separate and detailed consideration. In 
approaching their discussion, it is necessary to bear in mind several im- 
portant points in which the coecum differs from the rest of the large in- 
testine. Thus its peritoneal investment is deficient over the posterior 
part, which is generally quite firmly attached to the right iliac fossa by 
connective tissue, containing a small proportion of fat. Its anatomical 
relations moreover indicate that the semi-feculent materials passing from 
the ileum are destined to be retained in the coecum to undergo some im- 
portant action. The ileum at its lower portion rarely has a calibre greater 
than one-third that of the coecum, a circumstance which must materially 
retard the progress of the contents of the latter, and a further detention is 
caused by the ileo-coecal valve, which prevents all reflux, and by the posi- 
tion of the coecum, which compels it to force onwards its contents in oppo- 
sition to gravity. The view that the coecum is the seat of an important 
part of the digestive process, either in the appropriation of any remain- 
ing nutritious elements of the semi-feculent chyme, the absorption of its 
watery parts, or the elimination of some excrementitious matter from the 
system, receives confirmation from the very rich vascular and glandular 
supply of the walls of this part of the intestine. 






SEAT AXD CHARACTER. 405 

In addition to this, the ccecum has opening into it, usually at its lower 
and back part, the appendix vermiformis, a narrow, elongated, glandular 
process, varying from three to six inches in length, and having an average 
diameter about equal to that of a goose-quill, although its calibre is quite 
small. It is usually directed upwards and inwards behind the ccecum, 
and lies coiled upon itself. Its function appears to be the secretion of a 
viscid ropy mucus. 

"We thus see in the anatomical and physiological relations of the ccecum 
strong predisposing causes of many morbid conditions. Among these 
the most frequent are distension and. impaction of its calibre by hard- 
ened faeces ; the lodgement of a foreign body or intestinal concretion in 
one of its pouches or in the appendix, an accident which often excites 
violent and destructive inflammatory action ; and finally localized inflam- 
mation of one or all of the coats of the ccecum or the vermiform appendix. 

This last condition has received the names of typhlo-enteritis, from 
ruwXo^ blind, and evrepov, intestine ; typhlitis ; and ccecitis from the Latin 
word ccecum, also signifj'ing blind. 

The periccecal connective tissue is also occasionally the seat of infiam- 
matoiy action, constituting a condition known as perityphlitis. 

Seat and Character. — Clinical experience and the researches of patho- 
logical anatomy fullv justify us in recognizing the above-mentioned mor- 
bid conditions, but the question as to their relative frequency and import- 
ance is still far from being settled. 

By some authorities the diseases of the ccecum are regarded as second- 
ary to morbid affections of the appendix, the latter consisting generally 
of the presence of foreign bodies, or of hardened, inspissated mucus, 
which act as the focus and exciting cause of the inflammation of the 
ccecum. 

It is probable, however, in regard to the simple form of typhlitis, that 
both the ccecum and its appendix are subject to a peculiar localized in- 
flammation, involving all their coats, and due to the temporary arrest of, 
some foreign substance or intestinal concretion in their cavity, or to the 
action of one of the causes to be hereafter considered. It is indeed 
possible that the inflammation excited by the presence of a foreign body 
may subside, whilst the cause still remains arrested in the appendix or 
one of the pouches of the ccecum ; but experience would lead us to infer, 
that, when once inflammatory action has been excited, so long as the 
foreign substance which has caused it remains in contact with the mucous 
membrane, the tendency is usually to produce ulceration and perforation 
of the coats of the bowel. 

We find this same discrepancy of opinion in regard to those cases 
attended with perforation of some portion of the ccecum, and the forma- 
tion of an abscess in the iliac region. Dupuytren, who was the first to 
call attention to the pathology of these iliac abscesses, attributed them 
to suppurative inflammation of the periccecal connective tissue, produced 
in many cases by extension of inflammation from the coats of the ccecum, 
and held that the perforation of the bowel often found in connection, was 
a secondary phenomenon, and was in fact the mode by which the abscess 



406 DISEASES OP THE CCECUM AND APPENDIX CCECI. 

was discharged. Inflammation and suppuration of the periccecal tissue 
does indeed occur as an idiopathic affection, or from extension of inflam- 
mation from the coecum, but it is of extremely rare occurrence ; and there 
can be no doubt that nearly all cases of iliac abscess are due to perfora- 
tive ulceration of either the ccecum or appendix. As Bouchut suggests, 
one proof that most cases of non-puerperal iliac abscess are thus due to 
perforation of the ccecum or appendix, is afforded by their almost constant 
occurrence upon the right side. Thus of 57 non-puerperal iliac abscesses 
collected by Grissolle, 9 only were on the left side ; while of 26 puerperal 
ones, 15 were on that side. 

It is necessary, however, to carry this question one step further, and to 
determine, if possible, the relative frequency of perforation of the coecum 
and of the appendix. It has been supposed, as by Ferrall, that ulceration 
of the coecum is in most cases the starting-point in the development of the 
lesions. But, while we are in possession of a sufficient number of recorded 
cases, 12 of which we have collected, where post-mortem examination has 
proved the abscess to have originated in perforation of the coecum, there 
is good reason to believe that perforation of the intestine is much more 
frequently found associated with disease of the appendix than with ulcera- 
tion of the coecum itself. 

Causes. — In addition to the anatomical peculiarities of the coecum and 
appendix, which must be regarded as predisposing causes of these affec- 
tions, there are other conditions which exert an unquestionable influence. 

The strumous diathesis has been regarded as a predisposing cause of 
diseases of the ccecum and appendix. It does not appear, however, that 
inflammation of these parts is more frequent in strumous subjects, but 
merely that it has a greater tendency in such patients to run on to ulcer- 
ation and perforation of the bowel. 

Age. — The greater irritability and proneness to inflammation which the 
intestinal canal presents in early life, appears to have its effect upon the 
development of t3 T phlitis, since a considerable majority of reported cases 
have occurred under the age of 25 years. This is particularly true of the 
milder attacks, which are not attended with ulceration. Thus, of 38 cases 
of t} T phlitis at all ages, which recovered without perforation of the bowel, 
29 occurred at or under the age of 25 ; 9 only were in older persons. Of 
these 38, 13 occurred in our own practice, and were aged as follows: 2 
under 6 3 T ears ; 6 between 6 and 12 years ; 5 between 12 and 15 years. 
Finally, 19 of the 38 cases occurred at or under the age of 15 3'ears. 
This does not appear to hold true, however, with regard to perforative 
ulceration of the coecum and appendix. 

We have not met with any case of perforation of the coecum occurring 
during childhood, but of 25 cases collected from different sources, 13 oc- 
curred after the age of 25 ; 12 at or under that age. Of these 25 cases, 
12 only were verified by post-mortem examination, of which 3 were under 
15 } T ears of age, 2 between 15 and 25 3 T ears, and 5 above 25 3^ears. 

Of perforation of the appendix vermiformis, we have met with 3 cases 
in children, aged respectively 4^, 8, and 11 3 T ears. Of 25 other cases, 
collected from various sources, in which the age is stated, 9 were above, 






CAUSES. 407 

16 below 30 years of age. Of these 16, 3 only were under 15 years of 
age. so that, including our own 3 cases, we find 6 cases occurring under 
15 years, 13 between 15 and 30, and 9 above 30 years of age. 

Sex. — The influence of sex has been very variously stated by different 
observers. It appears, however, that males are somewhat more prone to 
all these forms of disease than females. Thus, of 39 cases of typhlitis, 
which recovered without perforation of the bowel, 23 were in males ; 16 
only in females. Of 13 of these 39 cases, which we observed in children, 
8 were males and 5 females. 

Of 25 cases of perforation of the ccecum, 13 occurred in males ; 12 in 
females. 

The sex is stated in 2t of 32 cases of perforation of the appendix. Of 
these, 21 were males ; 6 only were females. Of 6 cases occurring under 
15 3*ears of age, the sex is stated in 5, 4 of which were males. 

Occupation. — Tarious occupations, especially those involving sedentary 
habits, have been supposed to predispose to these affections, as also the 
practice among females of wearing tight corsets. Experience, however, 
has not verified these suppositions. 

Constipation* — A constipated state of the bowels undoubtedly predis- 
poses to these affections by favoring the production of a distended and 
impacted condition of the ccecum, even if the presence of the hardened 
fecal matter does not prove the exciting cause of some cases of typhlitis. 
Rokitansky considers this cause so important that he has given the name 
typhlitis stercoralis to one form of inflammation of the ccecum. 

Exciting Causes. — Cold and Exposure. — The action of these ordinary 
exciting causes has been denied by some observers on account of the fre- 
quent absence of a chill or rigor at the inception of the attack, and the 
development of the local before the general symptoms. It cannot, how- 
ever, be doubted that typhlitis may be idiopathic and arise from the ordi- 
nary exciting causes, though the cases are comparatively rare. 

Food. — In several instances the attack appears to have been brought on 
by the use of indigestible or irritating articles of diet, among which may 
be especially mentioned unripe acescent fruits. It has been said that the 
use of oatmeal, which favors the formation of intestinal concretions, is 
also liable to be followed by this disease. It does not, however, appear 
that typhlitis is any less frequent in countries where wheaten bread is 
used, than in those where oatmeal forms a chief part of the food. 

Bloios or Exertion. — There are a few cases recorded in which a blow 
upon the abdomen, or a sudden violent strain, appears to have been the 
immediate cause of an attack of typhlitis. 

Foreign Bodies and Intestinal Concretions. — This class, comprising 
very various substances, certainly forms the most important and frequent 
cause of diseases of the ccecum and appendix. 

We cannot be positive as to the amount of influence they exert in the 
milder and more tractable cases of simple typhlitis, though it is quite 
probable that many of these are caused by the temporaiy arrest of some 
foreign substance in the appendix, or one of the pouches of the ccecum. 
Thus, in a case reported by Dr. Wynn Williams (Lancet. January 25th, 



408 DISEASES OF THE COECUM AND APPENDIX CCECI. 

1862), in a male adult, three months after a well-marked acute attack of 
typhlitis, which yielded to judicious treatment, a large intestinal concre- 
tion, having a plum-stone for a nucleus, was passed by the rectum. The}' 
are, however, the efficient cause of a large majority of all the cases of 
perforative ulceration of the ccecum and its appendix. 

The diseases of this latter part, however, are far more uniformly de- 
pendent upon the presence of foreign bodies even than in case of the 
ccecum ; almost three-fourths of all recorded cases of perforation of the 
appendix having been due to this cause. In 6 cases occurring in children, 
some extraneous substance was found in the appendix in each one ; in 2 
a foreign body was present ; and in each of the other 4, an intestinal con- 
cretion. 

Many of these bodies are true intestinal concretions, having for their 
nucleus merely a nodule of hardened faeces or inspissated mucus. They 
vary considerably in size, the majority of them being about the size of a 
cherry-stone or date-stone, though Habershon mentions having seen one 
as large as a hen's-egg. The}' are also of veiy varying consistence, ac- 
cording to Yolz, as quoted by Hanbuiy Smith, constituting three varie- 
ties: the soft, resembling excrement in appearance and odor, and having 
a nucleus of hardened fecal matter ; the semi-hard, of a grayish-brown 
color, consisting of shining concrete layers, with a nucleus which is not 
a foreign body ; and the stony, which are of a grayish-white or earthy 
color, and have a surface from which may be detached delicate scales, or 
which is smooth, shining, yellowish-white, or brown, and studded with cal- 
careous projections. 

Many of these concretions consist of carbonate and phosphate of lime 
united with inspissated mucus. Copland also mentions one which con- 
sisted of cholesterine. 

In addition to these, however, numerous foreign bodies have been found 
in connection with the ccecum or appendix, either free or forming the nu- 
cleus of an intestinal concretion. Among these may be mentioned grape- 
seeds, cherry-stones, date-stones, pins, bristles, fragments of glass, biliary 
calculi, and balls of worms, either ascaricles or lumbricoids. 

It may not be amiss to remark, here, that some intestinal concretions 
resemble, to a marked degree, the seeds or stones of different fruits, par- 
ticularly of the cherry, date, and plum ; and there is no doubt that many 
of the bodies found in the ccecum or appendix, and reported as cherry- 
stones or date-stones, have been in reality intestinal concretions. 

Whatever be the nature and origin of these bodies, it is probable that 
in many cases some morbid condition of the mucous membrane of the 
ccecum or appendix precedes their formation or lodgement, and the de- 
velopment of the grave symptoms which often follow. 

As Habershon justly remarks, the ordinary calibre of the appendix is 
so extremely small and so thoroughly lubricated, that it must be very 
rare for any extraneous substance to become impacted in it so long as it 
remains health}'. A further argument in favor of this view is the fact 
that the presence of these concretions is attended by the most varying 
results, since very large and irritating bodies have been occasionally 









ANATOMICAL APPEARANCES. 409 

found occupying the cavity of the appendix without having produced any 
symptoms during life, or any inflammation of its surface ; while, on the 
other hand, minute concretions of semi-solid consistence, and apparently 
un irritating in character, have frequently been observed to act as the foci 
of the most serious and destructive inflammatoiy action. 

Anatomical Appearances. — In the simple forms of typhlitis, the mu- 
cous membrane of the ccecum presents the usual appearances of inflam- 
mation ; the peritoneal investment is also involved, and besides injection 
and opacity of this membrane, there are adhesions formed between folds 
of the intestines. 

When, however, ulceration is present, as often results from the pres- 
ence of foreign bodies, or in strumous subjects, it is a matter of the ut- 
most importance which portion of the ccecum is involved, since, as such 
ulcers have a strong tendency to perforate the coats of the bowel, if 
they occur on the anterior part of the ccecum, which has a peritoneal in- 
vestment, there is the greatest danger of an escape of the contents of 
the bowel into the peritoneal sac, and the development of rapidly fatal 
peritonitis. Thus, of 10 fatal cases of perforation of the ccecum, in 
which the seat of the perforation was determined by post-mortem exami- 
nation, the anterior wall was involved in six instances. If, on the other 
hand, the ulcer be seated on the posterior part of the ccecum, where it is 
attached to the iliac fossa b}- connective tissue, and devoid of a peritoneal 
covering, perforation is not directly followed by any such unfortunate 
results. Inflammation is excited in the periccecal connective tissue, sup- 
puration ensues, and the resulting abscess follows one of several courses, 
precisely as in idiopathic suppuration of the periccecal tissue. Thus it 
may reopen into the bowel ; may burrow along the sheath of the psoas 
muscle, and point below Poupart's ligament, or it may discharge in the 
lumbar region, or at any point along the crest of the ilium. 

In one case the iliac artery was opened, leading to speedy death from 
hemorrhage. 

Occasionally these abscesses discharge themselves by more than one 
avenue, as for instance through the bowel, and in the groin or iliac re- 
gion simultaneously. When, as occasionally happens, the inflammation 
of the ccecum passes into a chronic form and the ulcerative process ceases, 
the adhesions of the ccecum to the iliac fossa become preternaturally dense, 
the ccecum itself is contracted, its coats thickened, and the mucous mem- 
brane almost entirely destroyed, or converted into a retiform and trabec- 
ular fibroid tissue. Rokitansky has found in such cases the ccecum con- 
verted into a slate-colored capsule, with dense parietes, of the size of a 
walnut or a pigeon's egg. 

The appendix vermiformis may be the seat of catarrhal inflammation, 
associated with inflammation of its peritoneal covering. Death does not 
result from this condition, but the pathological appearances are probably 
analogous to those found in all cases of localized sero-enteritis. 

When, however, the appendix has been the seat of ulceration, and 
death has resulted before perforation has occurred, its cavity is found 



410 DISEASES OF THE CCECUM AND APPENDIX CCECI. 

distended with pus, its mucous membrane deeply uleerated, and in nearly 
every instance, a foreign body or an intestinal concretion is present. 

The ulceration of the appendix varies in its position and extent, at 
times being seated at the free extrenihVy, at others occupying the lower 
third of the appendix, which is perhaps the more frequent seat. In re- 
gard to its size, the ulcer and the subsequent perforation may be either 
veiy small, or else may involve almost the entire circumference of the 
appendix. 

Under favorable circumstances, especially if the foreign body is dis- 
charged, the ulceration ceases, and the appendix becomes converted into 
a ligamentous cord, its calibre being entirely obliterated. 

When perforation of the appendix occurs, the results vary according 
to the degree of local peritonitis which has been excited. If the appen- 
dix has become strongly adherent at the point where perforation is about 
to take place, this accident may not be followed by the development of 
general peritonitis. The points to which the appendix generally becomes 
adherent, are the coecum, the anterior abdominal wall, and the right iliac 
fossa. In the first case, the circumscribed abscess which follows the per- 
foration of the appendix will discharge itself through the coecum by 
effecting a perforation of its wall from without inwards, and this is the 
most favorable termination possible. When, however, the appendix has 
become adherent to the abdominal wall, or iliac fossa, the resulting ab- 
scess will follow the course, already described, of abscess from perforation 
of the coecum. 

It is in this connection that the various abnormal positions which the 
appendix may assume, are of importance, as determining the position in 
which the abscess will point. 

Unfortunately, however, the adhesions are rarely strong enough to 
circumscribe the purulent matters escaping from the appendix, so that 
these generally find their way into the peritoneal cavity, and excite gen- 
eral peritonitis. 

We subjoin the histories of 3 fatal cases of perforation of the appendix 
from intestinal concretions, occurring in children, in all of which some 
local peritonitis with adhesions had occurred, but had not sufficed to pre- 
vent the above unfortunate termination. 

Case 1. Intestinal concretion in the appendix coed, causing perforation 
and fatal peritonitis. — T. D. S., a healthy, well-grown boy, 11 years of 
age, rose on the morning of December 25th, 1860, apparently quite well. 
Soon afterwards, however, he complained of pain in the right iliac and 
lumbar regions, was chilly, and returned to bed. A dose of castor oil was 
given him. In the course of the day fever came on. 

Next day he was feverish, with a pulse of 132, a hot and dry skin, and 
a moderately furred tongue. The pain still continued, with tenderness and 
slight distension of the abdomen on the right side ; there was no vomit- 
ing. His bowels had been acted upon three times by the oil. Leeches 
and a poultice locally, and a mixture of blue pill with rhubarb syrup inter- 
nally, were ordered. 

On the 2tth and 28th the symptoms were much the same, except that 



CASES OF PERFORATION OF THE APPENDIX. 411 

the tenderness and distension increased. The pain was aggravated by 
coughing, by a full inspiration, and b} r motion, especially of the right 
leg. The bowels were slightly moved by the mixture ; no vomiting as 
yet. His fever continued, but the pulse fell to 108, and his skin was 
somewhat cooler. 

On the 29th he was worse. All his symptoms were aggravated, and 
vomiting set in ; his bowels became confined. Small doses of calomel 
and opium were given, enemata of various kinds were tried, and rhubarb 
syrup with a little fluid extract of rhubarb was perseveringly employed, 
but without effect. The abdomen now became greatly distended, exceed- 
ingly sonorous, and painful ; the stomach grew more and more irritable, 
rejecting from time to time, towards the last, with a sudden, spasmodic 
effort, everything that was taken by the mouth. The bowels were com- 
pletely obstructed, so that repeated injections of various kinds elicited 
no discharges, even of flatus. The urine continued to be secreted to the 
last ; and there was at times, in spite of the nausea and vomiting, quite 
a strong desire for milk and bread. 

During the last few days wine-whey and beef-tea were given in small 
quantities ; and opium by enema and by the mouth was used to allay 
pain. On the third day of the treatment a blister four inches square was 
applied over the seat of tenderness ; but neither this nor any of the other 
remedies employed seemed to exert the least effect upon the course of 
the disease. 

Death took place on the eighth cla # y, January 1st, 1861. 

The Autopsy was made by Dr. Packard, twenty-four hours after death. 
Bodj' large, muscular, and well formed ; rigor mortis well pronounced. 
Abdomen only examined. 

On making the usual section, several coils of small intestine, very 
greatly distended with gas, and markedly injected, with flakes of lymph 
here and there over the surface, at some points gluing the adjacent coils 
together, were seen concealing the rest of the abdominal viscera. After 
some search, the colon was found, very much contracted, except at the 
ccecum. The ileum was in like manner contracted, the narrowing begin- 
ning at about the end of the jejunum, which formed the distended coils 
above mentioned. No cause was assignable for the constriction at this 
point ; but a little lymph was thrown out here, and it may have been that 
the bowel had been twisted. 

The appendix vermiformis was bound down by peritoneal adhesions. 
Within it, near its origin, was a mass as large as a small bean, but per- 
fectly oval. Just beyond this mass, at what seemed to have been its 
position, was an ulcer extending all round the tube, and of a gangrenous 
aspect. At the distal end of this ulcer was a perforation, by which mat- 
ter had found an exit into the peritoneal cavhVy. The rest of the tube 
looked as if it had been distended by the pus before the opening was 
formed. After its escape from the appendix, the matter seemed to have 
caused a circumscribed peritonitis, in addition to the general one already 
indicated. The adhesions bounding this peritonitis had extended up to 
the liver, the convex surface of which was hollowed to a slight depth in 



412 DISEASES OF THE CCECUM AND APPENDIX COECI. 

an oval shape, the depression being lined by false membrane. The whole 
quantity of the pus was perhaps f^iv. 

The liver was pale in patches, but was not degenerated. Bather too 
large a number of oil-drops existed in a dark, inflamed portion of its sub- 
stance, just beneath the depression above mentioned; but even here the 
quantity was not great. The mesenteric glands were swollen and in- 
jected over the surface. Iso other lesions were observed. 

Case 2. Intestinal concretion in the appendix cceci, causing perfora- 
tion and fatal peritonitis. — C. B., ret. 4 i } T ears, was taken sick with slight 
fever, pain in the abdomen, some vomiting, constipation, and inflation 
of the abdomen. With these sjmiptoms there was marked tenderness 
in the right iliac fossa. After three da} T s, the bowels were well opened 
and the fever subsided ; the abdomen, however, continued inflated, and 
a small but distinct tumor had appeared just inside of the right anterior 
superior spinous process of the ilium. 

He continued to improve, and was apparently much better, but was 
strictly confined to bed, when on the ninth day at 3j p.m., he was seized 
with severe abdominal pain; sjunptoms of collapse rapidly appeared, and 
he died at 2 a.m., the following morning. 

At the autops} 7 an intestinal concretion of the shape and size of a clate- 
$tone, was found in the appendix. The end of the appendix was perfor- 
ated, and had become attached to the anterior wall of the abdomen, where 
a small abscess had formed in the cellular tissue between the peritoneum 
and the abdominal muscles, evidently seeking an outlet through the ab- 
dominal parietes. The wall of this had unfortunately ruptured into the 
peritoneal sac, and death had resulted in a few hours from general peri- 
tonitis. 

Case 3. B. P., a healtlry girl aged 7 i years, died at the end of the 
second week of a well marked attack of perforative disease of the appen- 
dix vermiformis. 

At the autopsy a large, rounded intestinal concretion was found in the 
appendix coeci, which was perforated, allowing an escape of matter into 
the peritoneal cavity. There was marked general peritonitis, with the 
formation of a large quantity of pus. 

Symptoms. — Mere distension of the ccecum by hardened faeces, without 
actual inflammation of its coats, may be attended with constipation, some 
vomiting, and the presence of a somewhat sensitive tumor in the coecal 
region. According to Copland, when the distension by accumulated 
matters is great, it may, from rising high in the abdomen and pressing 
upon the nerves, vessels, and ducts in its vicinhVv, occasion numbness 
and oedema of the right lower extremit} 7 , retraction of the right testicle, 
and derangement of the urinaiy secretion, so as to be mistaken for dis- 
ease of the kidney. 

Inflammation of the mucous membrane only of the ccecum, is gene- 
rally attended with a moderate degree of fever, slight pain and tender- 
ness in the right iliac fossa, and some diarrhoea, with mucous, offensive 
stools. This condition is not unfrequentry chronic, and evinces its pres- 
ence by no very positive s3 T mptoms, unless adjacent parts have become 
involved in the inflammation, or an acute attack of typhlitis supervenes. 



SYMPTOMS. 413 

Typhlitis, or inflammation of all the coats of the coecum or appendix, 
usually appears suddenly during full health, or it may be preceded by 
slight intestinal derangement, such as diarrhoea or constipation. 

Pain. — The earliest and most marked symptom is generally pain in the 
region of the coecum, which appears suddenly, becomes fixed and con- 
stant, rarely remitting, and is greatly increased by a deep inspiration 
or b} r coughing. 

This pain is attended from the very first with such exquisite tender- 
ness on pressure in the right iliac region, that the weight of the bed- 
clothes cannot be borne, and the patient shrinks from the lightest touch. 
To relieve this pain the patient lies toward the right side, with the thighs 
flexed upon the pelvis, and any attempt to draw the right leg down causes 
agonizing suffering. These local symptoms are usually confined to the 
right iliac fossa, though the entire peritoneum may become somewhat in- 
volved, and the symptoms of general peritonitis develop themselves. 

Fulness or Tumor. — Owing to the distended state of the bowel itself, 
and to the adhesions formed between folds of the intestines, or in some 
rare cases to an inflammatory effusion behind the coecum in the iliac fossa, 
there is marked fulness or even a well-defined tumor in the right iliac 
region. Frequently there will be merely fulness during the first few days 
of an attack, and then a distinct tumor will be developed. In 11 of 39 
cases of acute typhlitis, recovering without perforation of the bowel, a 
distinct tumor was present. In most of the other cases the condition of 
the coecal region is described as one of fulness or distension. Of these 
39 cases, 19 occurred in children under 15 years of age, in only 3 of 
which a distinct tumor is recorded to have been observed. 

Constipation. — The bowels are almost invariably constipated ; in many 
cases very obstinately so. This constipation is frequently associated with 
quite severe tormina and tenesmus, and if the coecum be much distended, 
there may be pain shooting down the right thigh, or numbness and even 
oedema of this part, together with retraction of the right testicle. 

It is important to observe here, that in most cases, when once the con- 
stipation is relieved, and free feculent stools procured, the most threaten- 
ing s3 7 mptoms of the attack rapidly subside. 

Vomiting nearly always attends in children ; it was present in all of our 
13 cases. It is never stercoraceous, and indeed is rarely troublesome 
unless the constipation is marked, or perturbating treatment has been 
adopted in the beginning of the attack. 

Fever. — The attack is not usually ushered in by any chill or rigor; but 
marked febrile symptoms soon appear, the pulse becomes accelerated, the 
skin hot, the tongue furred, and the thirst extreme. These symptoms 
usually subside under appropriate treatment after a variable time, gene- 
rally from four to twelve days ; the bowels are opened freely, the pain and 
tenderness diminish, and the fulness in the right iliac region gradually 
disappears. 

This description of symptoms applies to acute inflammation both of the 
coecum and appendix, as there are no well-recognized differences in the 



414 DISEASES OF THE CCECUM AND APPENDIX CCECI. 

symptoms of these two conditions. The only probable points of differ- 
ence are, that in inflammation of the appendix the pain is more acute, 
and the thorough evacuation of the bowels is not followed by the same 
prompt and complete relief. 

Perforation or the Ccecum. — When, however, perforative ulceration 
is progressing, the s} T mptoms follow a different course. The constipation 
may be relieved and the vomiting cease, but the local S} T mptoms persist, 
until the rupture of the bowel leads either to speedily fatal peritonitis, 
or to the effusio'n of fecal matter mixed with the products of inflammation 
into the pericoecal tissue. When this latter event occurs, the constitu- 
tional s}*mptoms soon indicate the occurrence of suppuration, and hectic 
irritation, with rigors or marked chills succeeded by drenching sweats, 
colliquative diarrhoea, rapid prostration and emaciation, with a dry brown- 
ish tongue and feeble running pulse, soon appear. Despite the desperate 
character of these s} T mptoms, however, recoveiy may- take place if the 
abscess points externally in the waj^ alreachr described, and does not open 
into the peritoneal cavity. It is. necessary to be aware that the approach 
of a fecal abscess to the surface is not attended with the appearances 
which usually accompairy the pointing of an abscess. Thus, instead of 
the skin becoming tense, prominent, and reddish, with a distinct sense of 
fluctuation present, the surface becomes douglry and dark-colored, and 
upon palpation a distinct sense of emphysematous crepitation is often 
obtained. Upon incising such a point, a discharge of fetid gas and 
grumous matter follows the puncture, and this peculiarity has more than 
once led surgeons to believe that they had opened a knuckle of intestine. 

Perforative Ulceration of the Appendix. — The symptoms of this 
disastrous condition closely resemble those of perforation of the anterior 
part of the ccecum. They are, however, often even more acute, the pain 
is sudden and violent, and a distinct tumor is more uniformly present ; 
while, on the other hand, the sjmiptoms of obstruction of the intestine 
are not so well developed. Constipation and vomiting are not constant 
in the early stage, and at a later period spontaneous diarrhoea may ap- 
pear, but without an} T favorable result. The perforation of this part is, 
as alread}^ said, far more apt to be followed b} r general peritonitis ; and, 
indeed, so far as we know, there is but one well-authenticated case on 
record of recoveiy after this accident, which was published by one of 
ourselves in the Proceedings of the Pathological Society of Philadelphia. 
(See Amer. Jour. Med. Sciences, vol. liv, July, 1867, p. 145.) 

Perityphlitis, or inflammation of the pericoecal tissue, when it does 
occur independently of typhlitis, is ushered in hy pain, with deep-seated 
tenderness in the right iliac region. There is also some fulness of this 
part, but not the formation of a distinct tumor, as may frequently be 
detected in t3 T phlitis. There are usually colicl^y pains in the abdomen, 
with either constipation or diarrhoea, and with a moderate degree of 
febrile excitement. This disease, when judiciously treated, frequently 
seems to terminate in resolution ; when, however, suppuration occurs, the 
sj-mptoms will approximate those given above, and the abscess which 



DURATION — PROGNOSIS — DIAGNOSIS. 415 

forms may discharge itself externally, into the bowel or into the peri- 
toneal cavity. 

Duration. — Many attacks of acute t} T phlitis, when promptly and ju- 
diciously treated, yield on the second or third clay ; though the case is 
often prolonged to the ninth or twelfth day, and, in violent attacks, it 
may be man}' weeks before all local tenderness in the ccecal region passes 
away, and the function of the bowel is again completely restored. 

When perforation of the ccecuni occurs, the after-duration of the case 
depends entirely upon the point of perforation. If the ulcer have pen- 
etrated the anterior wall, general peritonitis is usually excited, and death 
results in less than forty-eight hours. But if, on the other hand, the pos- 
terior wall be perforated, a fecal fistula may be formed, and continue open 
for xerj many years. The duration of perforate ulceration of the ap- 
pendix varies considerably. In 3 cases in children, observed by ourselves, 
the duration was respectively seven, nine, and fourteen days, with a mean 
of ten da3's. 

In 11 cases, at all ages, in which the duration is distinctly stated, the 
mean duration was nine days, the extremes being two and a half and 
twenty-nine days. • 

Bamberger, however, gives the duration of seven cases, occurring at 
various ages, at from twent}* to fifty da}'s, with a mean of thirty-one cla} T s. 
It is probable, however, that this last mean is rarely attained in cases 
occurring in children. 

Prognosis. — Nearly all cases of simple acute typhlitis, without perfora- 
tion of the bowel, recover under proper treatment. Indeed, there are no 
cases on record of acute typhlitis proving fatal, in which post-mortem 
examination did not show the existence of perforation of the ccecum or 
appendix. 

When the ccecum has become the seat of chronic inflammation, how- 
ever, death may result, either from the sudden development of acute peri- 
tonitis, without ulceration of the bowel, or from such contraction of the 
ccecum as finally to lead to obstruction of the intestine. 

When perforation of the ccecum does not prove speedily fatal from peri- 
tonitis, but leads to the formation of an abscess in the iliac fossa, the prog- 
nosis of the case depends, in a considerable degree, upon the course taken 
by this abscess. Dupuytren regarded the reopening into the bowel as the 
safest termination of an iliac abscess, and the opening upon the surface 
of the body as almost universally fatal. Further experience has confirmed 
the truth of the first portion of this opinion, but has also established the 
fact, that almost one-half of the abscesses opening externally recover. 

Perforation of the appendix vermiformis is invariably fatal, so far as 
our experience goes, if we except the case before referred to, where, in 
an old man about whose past history nothing could be learned, we found 
the appendix converted into a solid fibrous cord, with a small opening, 
near the free extremity, leading to its centre. 

Diagnosis. — The general diagnosis of most of these conditions is not 
attended with much difficulty. We have already mentioned that simple 
excessive distension and impaction of the ccecum is sometimes attended 



416 DISEASES OF THE CCECUM AND APPENDIX C(ECI. 

with severe pain, some tenderness, constipation, and even vomiting, and 
that these symptoms are relieved upon free action of the bowels being se- 
cured. We do not have here, however, the sudden attack occurring in a 
state of perfect health, as in typhlitis, nor the marked febrile sjinptoms ; 
nor are the local signs in the right iliac fossa, and especially the peculiar, 
exquisite sensitiveness, nearly so well developed. 

Inflammatory disease, in connection with the right ovary, with local 
peritonitis, is unquestionably sometimes mistaken for typhlitis. The local 
symptoms in the former affection are, however, lower down in the abdo- 
men than is usual in typhlitis ; there is not the well-defined tumor nor 
the obstinate constipation ; and, in addition, there is generally the history 
of some menstrual trouble, or the attack occurs in immediate connection 
with the period of menstruation. 

Pain in the course of the last dorsal nerve may arise from spine dis- 
ease, or, in the course of the genito-crural nerve, from the passage of a 
renal calculus, and, according to Habershon, be confounded with coecal 
disease. It is evident, however, that most of the characteristic S3anp- 
toms of typhlitis would be absent, whilst a careful investigation of the 
case would probably educe more symptoms of the existing trouble. 

The diagnosis of typhlitis from intussusception, an affection which 
presents many features of resemblance, will be fully considered in the 
article devoted to this latter disease. 

Ulceration of the coecum or appendix may be suspected, if the violent 
pain and the exquisite tenderness persist in the right iliac region, after 
the other symptoms of an acute attack of coecal disease, especially the 
vomiting and constipation, have been overcome. Ulceration of the 
coecum is much more apt to have been preceded by bowel complaint for 
some time ; it is also mach more rare than ulceration of the appendix. 

In cases where we are cons Lilted only after perforation has taken 
place, with the production of a fecal abscess, we must endeavor, by 
obtaining a most accurate history of the case, to establish the presence 
or absence of sjTnptoms of inflammation of the coecum at the beginning. 
And further, care must be taken to exclude the following conditions, all 
of which may at times simulate iliac abscess, namely : psoas abscess, or 
abscess connected with caries of the pelvic bones ; abscesses in the walls 
of the abdomen, with local peritonitis, resulting from blows ; suppuration 
originating in connection with the right kidney or its envelope ; and 
finally, some cases of disease of the right hip-joint. 

The differential diagnosis of these affections of the coecum and appendix 
from one another is as yet scarcely possible. The following general 
remarks contain, perhaps, all that can be surely advanced: 

Simple inflammation of the appendix presents symptoms of even greater 
acuteness and severity than those of simple coecitis, and which do not 
subside so promptly after the bowels have been freely acted upon. 

In ulcerative disease, both of the coecum and appendix, the symptoms 
also persist after the constipation and vomiting have yielded. 

Ulceration of the coecum, however, is rare, and is apt to be preceded 
by symptoms of bowel complaint. Whilst ulceration of the appendix, 



TREATMENT. 417 

on the other hand, is often terribly acute, advancing from a state of 
apparent perfect health to perforation and death in forty-eight hours ; 
it is also much more frequently attended with a distinct tumor in the 
right iliac region. 

Treatment. — The indications for treatment in the acute stage of 
typhlitis are clearly to reduce the local inflammation of the peritoneum 
and intestine, to relieve the pain and tenderness, and to secure free and 
natural action of the bowels. At the same time, all perturbating and 
strongly reducing treatment is forbidden, by the knowledge that the 
attack is frequently caused by an irritating foreign body ; and that, in a 
certain number of cases, perforation will occur, in wmich event the only 
hope of recoveiy often rests upon the adhesions which have been formed 
during the early stage, and upon the vigor of the constitution to resist a 
prolonged and exhausting process of suppuration. 

Depletion. — The local abstraction of a few ounces of blood by the 
application of leeches to the ccecal region, should be practised in acute 
cases. This measure, while it does not seriously reduce the strength of 
the patient, relieves the pain and tenderness, and probably facilitates the 
action of the internal remedies employed. Bej^ond this degree, however, 
depletion is injurious, or, at least, unnecessary. 

Purgatives. — The experience of all observers agrees in condemning the 
use of powerful, irritating purgatives at any stage of typhlitis. In the 
early stage, they aggravate the pain and inflammation, increase or estab- 
lish vomiting, and frequently fail entirely in their object ; while, on the 
contrary, the constipation which will resist the strongest, most drastic 
purgatives, will quickly yield to mild, saline, or vegetable laxatives. 

It is a good plan to combine a small amount of opium with the laxa- 
tive ; since, so far from counteracting its operation, it appears, by allay- 
ing the intense sensitiveness of the bowel, to promote its painless and 
thorough action. 

Burne recommends highly the following laxative draught, the dose of 
which is arranged for an adult : 

R. — Sodie Sulphatis, ^j. 

Tr. Opii, gtt. v. 

Inf. Sennge, f^j. 

Ft. sol. S. — Repeat every four hours until the bowels are freely moved. 

We have ourselves been led by experience to rely upon the combina- 
tion of comp. ext. coloc3 r nth with opium, given in small and frequently 
repeated doses. Thus, for a child of from five to eight years, the follow- 
ing pill may be prescribed : 

R. — Pulv. Opii, gr. ij or iij. 

Ext. Colocynth Comp., . . . . gr. xij to xviij. 
Ft. mas. et div. in pil. No. xxiv. 
S. — One every three or four hours until free action of the bowels is secured. 

Enemata. — The action of these laxatives may be furthered by the 
administration of large enemata, which may consist either entirely of 

27 



418 DISEASES OF THE CCECUM AND APPENDIX CCECI. 

tepid water, or of water containing a small proportion of some stimulat- 
ing or laxative substance, such as soap, molasses, or castor oil. In cases 
where the irritability of the stomach precludes the administration of laxa- 
tives by the mouth, enemata become especially important, and at times 
their use will be followed by the most happy results, the irritating con- 
tents of the ccecum being brought away with almost immediate relief to 
the most threatening symptoms. 

Mercury. — It is difficult to support the practice of giving this drug in 
typhlitis. In the early stage, indeed, when it may be supposed that the 
intestinal canal contains irritating ingesta and secretions, a small dose 
of calomel or blue pill may be administered ; and, in a large number of 
the successful cases on record, this was done. It is not, however, at all 
necessary. Be} T ond this, the further use of mercury appears to us injuri- 
ous, since, if it be given until any constitutional effects are produced, it 
must have a tendency to prevent the formation of those strong adhesions 
which constitute the sole chance of recovery in case of perforation of the 
appendix or the anterior wall of the ccecum. 

Opium. — TVe have already mentioned the way in which opium is most 
advantageously given in this affection, in combination with the laxative 
employed. Its use is absolutely called for, and the violence of the local 
symptoms, the pain and exquisite tenderness, form the best guide as to 
the amount required. 

Poultices and Gounterirritants. — In case even the local abstraction of 
blood appears undesirable, resort should be had to the frequent applica- 
tion of mustard plasters or turpentine stupes to the coecal region. Hot 
fomentations or light poultices, to which some sedative substance ma}^be 
added, should be kept constantly applied to the abdomen. 

Vomiting when present, should be allayed b}^ count erirritation, by 
swallowing small fragments of ice, b}" carbonated drinks, hydrocyanic 
acid, or anj" other suitable remedy. 

The diet during the early stage should be fluid, and unirritating in 
character. 

When the persistence of the symptoms leads us to apprehend the pres- 
ence of ulceration, either of the ccecum or appendix, all depletory and 
perturbating treatment should be abandoned, and we should limit our 
efforts to the relief of pain, by the use of opium and the continued appli- 
cation of poultices; to regulating the functions of the intestinal canal, 
and to the sustentation of our patient's strength. 

If perforation has occurred, without the speedy development of general 
peritonitis, our attention should be mainly directed to supporting the 
system during the long and exhausting process of suppuration which 
must ensue. For this purpose a generous, though digestible diet, with 
as much stimulus as appears necessary, should be enjoined; and resort 
may also be had to the various tonics, as quinia and the preparations of 
bark. If a tumor forms, and it becomes evident that the abscess is tend- 
ing to discharge externally, its approach to the surface should be en- 
couraged by poulticing ; and the moment an emphysematous condition 
of the skin is detected at any point, a free incision should be made, and 



INTUSSUSCEPTION. 419 

the discharge of matter furthered by the introduction of a sponge tent 
or a pledget of lint, and the application of a poultice. 

In those unfortunate cases where the perforation of the bowel has been 
followed by general peritonitis, all treatment is unavailing. Our main 
reliance must, however, be placed upon the exhibition of opium, and the 
use of counter-irritation. 



AETICLE YI. 

INTUSSUSCEPTION . 

Definition; Synonymes; Form; Frequency. — Obstruction of the in- 
testinal canal, from one or another of the numerous causes capable of pro- 
ducing it, is an accident liable to occur at all periods of life. But the 
variety of it which forms the subject of this article is of rare occurrence 
excepting in early childhood. It has been called ileus, volvulus, miserere 
mei ; but is best known under the descriptive names of intussusception or 
invagination of the intestines. It consists in the passage or introduction 
of one portion of intestine within another, as a small tube might slide into 
a large one, or, to borrow a familiar illustration, as the end of a glove finger 
may be pushed back upon itself into the glove. This simple invagina- 
tion, however, is not the only element present, for in order that the symp- 
toms of intussusception should be produced, it is necessary that the in- 
cluded portion of bowel should be so incarcerated and constricted as to 
give rise to more or less complete intestinal obstruction. This has led to 
a very just division of intussusceptions into such as are slight, unattended 
by inflammation, or spasmodic; and such as are grave, or attended by 
inflammation and incarceration. The slight form of invagination is found 
very frequently at autopsies of children who have died of other diseases, 
and in whom during life there was no symptom of disturbed function of 
the alimentary canal : it is in all probability produced in the death agony. 

M. Louis states that the greater part of 300 children dying during the 
period of dentition at the Salpetriere, had 2, 3 or even 4 volvuli without 
inflammation. 

Baillie, Cheyne, and Billard speak of such intussusceptions as being fre- 
quently found at the autopsies of children ; and Burns, as quoted by Gor- 
ham, 1 gives the results of the autopsies of 50 children who had died from 
diarrhoea, in every one of which they were found. This species of invagi- 
nation in children occurs almost exclusively in the small intestine ; the 
invaginated part is usually of no considerable length; and the very 
slightest traction suffices to restore it. 

The grave form, on the other hand, differs from this alike in the very 
positive symptoms by which its presence is announced, in the condition 
of the parts involved, and in the part of the bowel affected ; and as the 



Guy's Hosp. Reports, 1st series, vol. iii, 1838, p. 330. 



420 INTUSSUSCEPTION. 

form first mentioned scarcely deserves to be called a disease, it is to the 
latter alone that the following remarks are addressed. 

Frequency. — Although numerous well-authenticated cases of intussus- 
ception occurring in adults are on record, statistics prove that it is rela- 
tively much more frequent during the first four years of life. Thus of 100 
cases given by Duchaussoy 1 in which the age is mentioned, there were 31 
under 4 years of age, 6 between 4 and 10 years, and 63 adults. Smith's 2 
tables go to show that "this complaint is rare under the age of 3 months, 
and that the period of greatest frequency is from the third to the sixth 
month of life, the maximum number being at the fourth month." Thus 
there were 11, of the 50 cases collected by him, at the age of 4 months, 
or 21 in all between 3 and 6 months inclusive; 8 from 6 months to 1 } T ear ; 
and only 18 between the ages of 1 and 12 years. 

We must, however, call attention to the rarity of this disease at any age 
among us ; for although, in the course of a very extensive practice among 
children in this city, we have met with several well-marked illustrations 
of the various forms and terminations of intussusception, it has been one 
of the rarest occurrences in our experience. 

Anatomical Appearances. — Intussusceptions, anatomically consid- 
ered, may be divided into descending or progressive, and ascending or 
retrograde, according to the direction which the invaginated portion 
takes ; and into central or lateral, according as the entire intestine, or 
but one wall, is invaginated. Lateral invaginations, however, are exceed- 
ingly rare, occurring but twice in 131 cases collected by Duchaussoy. 

Excepting when invagination occurs as a complication of some other 
affection, it is almost invariably of the descending form. Thus, of Du- 
chausso3 7 's 137 cases, only 16 were retrograde, all of them being compli- 
cated ; and Haven gives but 3 instances of ascending intussusception out 
of 59 cases. 

It is a matter of considerable importance to determine what is the most 
frequent seat of intussusception in children. Eilliet and Barthez 3 declare 
that in infants the small intestine is almost never the seat of intussuscep- 
tion, but that ordinarily it is the lower end of the ileum which is invagi- 
nated into the large intestine. The reasons for this are found in the 
anatomical conditions of the intestines in infancy : the adhesions of the 
ccecum to the right iliac fossa being much more limited and less powerful 
than in later life ; and the muscular coat of the ccecum being but slightly 
developed in childhood, a circumstance which must also tend to favor the 
passage of the lower end of the ileum through the valve. 

The statistics of Duchaussoy and Smith confirm this opinion ; as of 31 
cases of simple descending intussusception in children under 4 j^ears of 
age, collected by the former, the large intestine alone, or both the large 
and small, formed the intussusception in all but 4 cases ; and Smith 

, r<) ■ 

1 Duchaussoy, Mem. de l'Acad. de Med., vol. xxiv, p. 97 (New Syd. Soe. Year 
Book, 1863, p. 294). 

2 Smith, Statistics of Intussusception in Children (Am. Jour. Med. Sci., vol. xliii, 
1862, p. 17). 

3 Mai. des Enfants, 2eme ed., torn, i, p. 806. 



ANATOMICAL APPEARANCES. 421 

states that he has found no exception to Rilliet's remark, as regards 
early infancy. In children above the age of 2 years, fatal invagination 
in the small intestines ma}- occur in rare cases. In a few cases also, the 
ileum has preserved its normal relations to the ileo-coecal valve, the 
coecum being the first part inverted, and drawing after it the lower end 
of the ileum. 

An intussusception, then, is made up of three folds of intestine: 1st, 
The inner, or contained part, which in descending intussusceptions is 
always in the natural direction ; 2d, The middle, which is a reflection of 
the inner, and passes in a direction contrary to the intussusception ; and 
3d, The outer, containing part or sheath, which is in its natural position, 
and in the direction of the intussusception. We find, therefore, the 
mucous membrane of the middle and outer parts in apposition ; and the 
peritoneal investment of the middle and inner parts in contact. 

The amount of intestine invaginated and the condition of the parts de- 
pend, in great measure, upon the duration of the case. If death takes 
place early, only a small portion of the ileum may have passed the valve ; 
but as the case progresses, the tenesmus or the active peristaltic action 
of the outer part, brings down more and more of the ileum with its ac- 
compairying mesentery, until finally, the constriction of the ileo-coecal 
valve preventing the descent of any more of the ileum, the coecum is in- 
verted and forced into the ascending colon. This in turn may be invagi- 
nated in the descending colon and rectum, until not unfrequently a 
portion of the invaginated intestine protrudes from the anus. In rare 
cases, the whole invaginated mass descends into the intestine below, thus 
forming a double intussussception of great thickness. It has occurred, 
in a few rare cases, that the amount of constriction was so slight that 
the intestine remains pervious to a certain extent ; so that life has been 
protracted for many weeks, and death has finally ensued only from ex- 
haustion. But ordinarily the parts are in the following condition : the 
intestine above the point of constriction is distended with gaseous and 
fecal contents, and more or less discolored from congestion of its walls. 
It is rare, however, to find any evidences of enteritis either here or in the 
intestine below the intussusception, which is generally pale and con- 
tracted. The invaginated portion itself, at the upper part, where it seems 
to plunge into the containing portion of the intestine, presents a series 
of concentric circular folds. The walls of the bowel thus incarcerated 
are thickened and infiltrated ; their serous investment either deeply in- 
jected or discolored by congestion and ecchymosis, so as to be of a deep 
blackish-red color ; and frequently evidences of local peritonitis are pres- 
ent. The mucous membrane in cases of short duration may be merely 
thickened and injected, but more frequently it is turgid from congestion, 
ecchymosed in points, and shows the effects of violent inflammation by 
its unequal roughened surface, presenting either ulcerations or grayish 
false membranes. The capillaries of the constricted portion become 
greatly distended, so that, especially in young children, in whom the 
vascular rete of the intestines is remarkably rich, whilst the tissues are 
delicate and yielding, they frequently rupture, filling the invaginated in- 
testine with blood, and producing bloody discharges. 



422 INTUSSUSCEPTION. 

If the case is protracted and the powers of life sufficient, when treat- 
ment has not sufficed to reduce the intussusception, nature endeavors to 
effect a cure by eliminating the invaginated portion. The incarcerated 
bowel becomes gangrenous, a line of separation forms, union and cicatri- 
zation takes place between the part of the bowel above the intussuscep- 
tion and the upper part of the containing intestine, and the invaginated 
portion is discharged per anum. This process of elimination is extremely 
rare in infants ; but it is stated by Rilliet to be the ordinaiy method of 
cure in children in their second infancy. In 59 cases reported by Haven, 1 
of all ages, discharge of the intestine per anum took place 12 times, with 
recovery in all but two cases. The average length of intestine passed in 
these cases was 23^- inches ; in the two fatal cases, the portions passed 
were respectively 39 and 44 inches long. The earliest age at which we 
have met with this process of cure, is at 13 months in a case reported by 
M. Marage. 

In the report of the Proceedings of the Pathological Society of London, 
vol. xiii, a specimen is described by Dr. Hare, where this process had 
taken place. The patient was a female, 41 } T ears of age, and her death 
resulted from tubercular disease three months subsequently to the pas- 
sage of the sphacelated bowel, "which was 6j inches in length, of a very 
dark purplish-gray color : it formed a perfect cylinder, but the intestine 
was turned inside out, the exterior of the specimen, as voided, being the 
mucous membrane, and the interior of the cylinder being the peritoneal 
covering of the intestine." 

At the autopsy, at the point where the invaginated portion had been 
separated, about fifteen inches above the ccecum, the line of union was 
found running obliquely across the intestine, " but the union was so per- 
fect that it could scarcely be detected except by holding up the intes- 
tine between the eye and the light, when the thinness of the intestine 
clearly pointed out the line or seam where the union had taken place. 
Exactly at the point of union the intestine was notably narrower than 
natural ; but the intestine above this point was a little dilated." 

We have recently had an opportunity, through the courtesy of Prof. 
A. Stille, of studying a specimen in which a similar process of cure had 
been effected. The patient was an adult, who died of some chronic dis- 
ease, and no histoiy could be obtained of the occurrence of the attack of 
intestinal obstruction, or of the discharge of the sphacelated portion of 
bowel from the anus. The specimen, however, presented appearances 
which left no doubt that invagination of a portion of the ileum had oc- 
curred, that the invaginated portion had sloughed away, and that union 
had taken place between the intestine, just above the intussusception, and 
the upper part of the sheath, so as to preserve the continuity of the bowel. 
The external surface presented a marked constriction encircling the in- 
testine, due to the entrance of the upper part of the bowel into the sheath. 
There was a layer of organized lymph investing the peritoneum at the line 
of junction, and firmly uniting the two serous surfaces. Upon laying 

i Haven on Intestinal Obstruction, Amer. Jour. Med. Sci., vol. xxx, 1855, p. 351. 



causes. 423 

open this part of the ileum, a narrow rim of indurated tissue, evidently 
the altered intestinal wall, projected downwards into the intestine from 
the line of constriction, and formed, as it were, a perforated diaphragm 
across the calibre of the bowel. 

We thus see that even when the slough is cast off, and the patient re- 
covers from the intussusception, the cure is not always permanent, since 
in a small proportion of cases there may be serious contraction of the 
bowel, caused by the ensuing cicatrization. 

In addition to the modes of recovery already adverted to, namety, the 
reduction of the intussusception either by the movements of the bowel 
itself or by the remedial measures adopted, and the elimination of the 
invaginated portion, there is still a third mode possible, in which the 
intestine remains invaginated, but b}^ agglutination of the outer folds, 
becomes pervious, and undergoes such atrophy and contraction as not to 
interfere materially with the functions of the bowel. Rilliet and Barthez, 
as well as other Continental authors, speak of this as of occasional occur- 
rence, but we have not found any well-authenticated cases recorded. 

There are few morbid changes found in intussusception excepting those 
pertaining to the intestines. It is, howeA T er, worthy of mention, that in 
some cases the invaginated mass appears to produce serious compression 
of the large vessels of the abdomen. 

Causes ; Age. — T\ r e have already given the statistics wdiich prove that 
intussusception is relativel} T very much more frequent during the first 
four years of life, the period of maximum frequency being between the 
third and sixth months. It is very rare before the age of three months. 
All forms of invagination, however, do not occur with equal frequency at 
these various ages. During early infancy, for the anatomical reasons 
already assigned, the almost invariable seat of the invagination is the 
lower end of the ileum and the upper part of the large intestine; while, 
after the age of two years, invaginations of the small intestine alone, 
though still very rare, may occur. 

Sex. — All statistics agree in giving a majority of males over females, 
at least in the proportion of 2 to 1 ; while in some tables the proportion 
is as high as T to 1 ; thus Rilliet and Barthez collected 25 cases, of which 
22 were boys. 

Previous Condition. — In by far the majority of cases, intussusception 
in the infant occurs as an idiopathic affection, appearing during perfect 
health. In children over one or two years of age, however, it is much more 
apt to be preceded by some disturbance of the alimentaiy canal, as con- 
stipation, diarrhoea, dysentery, or even by symptoms of imperfect ob- 
struction of the intestines. 

Intussusception may also occur during the course of other diseases, as 
in a case quoted b} r Rilliet from Legoupil, where the invagination ap- 
peared during the progress of variola ; the child, 4J years old, recovered. 

Exciting Causes. — External violence, as blows upon the abdomen, or 
sudden jerking of the child's bod} T , as in tossing it in the arms, are 
assigned as the probable exciting cause of a certain number of cases. It 
has been supposed, also, that violent fits of coughing or screaming, or 



424 INTUSSUSCEPTION. 

strong straining at stool, have produced invaginations, especially in very 
young children. 

Improper alimentation and sudden changes of diet, appear to act 
quite frequently as efficient causes ; thus in a case reported by Gorham, 
occurring in a healthy infant of four months old, the only assignable cause 
was the administration of panada for three da} T s preceding the attack. It 
is, however, frequently impossible to assign any plausible reason for the 
sudden production of severe intussusceptions. 

Granting, however, the presence of any of these causes, the question 
still remains as to the exact mechanism of the invagination. According 
to Gorham, " it is necessaiy to the production of an intussusception that 
there should be either; 1st, A contraction of the part to be intussus- 
cepted; or 2d, A dilatation of that part which is to be the outer fold ; or 
3d, A natural and sudden inequality of calibre of some portion of the 
intestinal tube. The first of these conditions may be produced by spasm ; 
the second by flatus ; whilst the third is alwa} T s present at the termination 
of the ileum in the ccecum." It is at this point, accordingly, that intus- 
susception most frequently occurs, and, from the anatomical arrangement 
of the parts making it very difficult for restitution to occur, puts on its 
most dangerous and fatal characters. 

The invagination having once begun, its increase and persistence are 
probably due to the active peristaltic action of the outer fold, aided by 
the spasmodic contractions of the diaphragm and abdominal muscles, 
causing the powerful tenesmus so frequently observed. 

There is one more question in regard to the etiology of this affection, 
about which various opinions have been expressed ; whether, namely, 
enteritis holds the relation of cause or effect to intussusception. Rilliet 
and Barthez appear to us to have given it its true importance in stating 
that it sometimes plays one part and sometimes the other. We have 
already seen that, though in many cases intussusception occurs suddenly 
in full health, there are a sufficient number of instances where the attack 
has been preceded b} T symptoms of intestinal irritation or inflammation, 
to make it clear that at times enteritis acts as a predisposing or deter- 
mining cause. And, on the other hand, the pathological anatomy of the 
disease, showing the inflammation of the bowel to be limited to the im- 
mediate vicinity of the invagination, and to be the more intense as the 
constriction is tighter, proves that enteritis frequently appears as a result 
of intussusception. This becomes especially evident in those cases where 
the disease has been caused b} T external violence, and where after death 
the above conditions have been noticed. 

Symptoms; Duration; Terminations. — The principal symptoms of 
intussusception are furnished by the gastro-intestinal apparatus ; and, 
towards the termination of unfavorable cases, by the nervous system. 
We have seen that a considerable difference exists in the seat of the 
invagination at different periods of childhood, and in examining the sjmrp- 
toms we find a corresponding disparity, according as the intussusception 
occurs in the first infancy, under the age of 2 }*ears, or in the second in- 



SYMPTOMS. 425 

fancy, between the second and sixth 3~ear. These points of difference 
will be mentioned, as each symptom is discussed. 

The most important and characteristic sj-mptoms are: vomiting, con- 
stipation, and bloody discharge from the anus; abdominal pain, tenesmus, 
and protrusion of the intestine, the presence of a tumor in the abdomen, 
and tympany. 

Vomiting is an almost constant symptom; being present in about 95 
per cent, of the cases. Very rarely the gastric disturbance amounts only 
to nausea, but nearly always vomiting sets in early in the attack and per- 
sists, despite all treatment, until either the invagination is relieved, when 
it promptly ceases ; or until the approach of death. Quite frequently it 
ceases a day or two before the fatal event occurs. The matters vomited 
at first consist of the ingesta, the stomach rejecting everything taken into 
it ; soon, however, they become mixed with mucus and bile. In very 
young children, it is rare for stercoraceous vomiting to occur, but in those 
who are above two 3'ears of age it may occasionally be present. In Smith's 
50 cases, it occurred in three, at the respective ages of 3, 6, and 11 years. 

The condition of the bowels is generally one of obstinate constipation, 
so far as the passage of fecal matters is concerned. It is not unusual for 
one natural abundant stool to occur after the intussusception begins, but 
this is succeeded hy constipation. It is only in those very rare cases 
where the invaginated portion remains pervious, that a small amount of 
fecal matters finds its way into the stools. 

The discharges which, however, do take place almost invariably in intus- 
susception in children, are due to the rupture of the capillaries of the con- 
stricted bowel, and consist of blood mixed in varying proportions with 
mucus and serum. It is rare for the blood to be so deficient, that the 
discharges resemble the gelatinoid mucous discharges of dysentery, 
merely streaked and tinged with blood, whilst, at times, the blood is in 
such excess as to appear pure, and to constitute a true intestinal hemor- 
rhage. This symptom, the true value of which was first recognized by 
Gorham and Clarke, 1 is of more uniform occurrence in children under 
two years, on account of the greater ease with which the intestinal capil- 
laries give way in infanc}^. Thus of 26 children under one year of age, 
bloody evacuations occurred in 23, usually several times in the twenty- 
four hours ; in 2 of the 26 there is no record of this symptom, and in 1 
only is it recorded as absent. In case No. 2, of Mr. Gorham's table, a 
child of 3^ months passed within a few hours more than a teacupful of 
fluid blood. In older children, on the other hand, bloody discharges 
occur less frequently; thus Smith records 18 cases of invagination between 
one and two years, in only 6 of which it is stated that there were bloody 
motions. 

We have already mentioned the various ways in which recovery takes 
place, and when elimination of the invaginated portion is about to occur, 
which is almost exclusively limited to cases occurring in the second in- 
fancy, the stools become highly fetid, contain more or less blood, are 

1 London Lancet, January, 1838. 



426 INTUSSUSCEPTION. 

blackish or brownish in color, and are soon accompanied by the discharge 
of the slough. The interval elapsing between the inception of the attack 
and the discharge of the portion of bowel, varies considerably in different 
.cases, but seems to be less in childhood than in adult age. Thomson 
v states that in adults, the elimination takes place in the majority of cases 
within thirty days ; and in one of his cases it occurred as early as the 
sixth day. In children the interval rarely exceeds twelve da} r s ; and the 
average of all recorded observations would seem to fix about nine daj T s 
as the usual time. 

Abdominal pain is among the earliest aud most constant symptoms at 
all ages. During the early part of the attack, it appears in parox3 T sms ; 
and may be detected even in the youngest children, by the violent parox} T s- 
mal screaming, and contortions of the limbs and trunk. At the com- 
mencement, the abdomen is generally relaxed, supple, and indolent ; and 
this condition may remain until death, perhaps because the constriction 
in some cases is not complete and allows the passage of gas. But after 
a few days, there is apt to be more or less continuous pain and soreness 
on pressure in the part of the abdomen corresponding to the invagination, 
due to the local enteritis and peritonitis. This may or may not be ac- 
companied hj t} T mpany and diffuse tenderness of the abdomen; but, as a 
general rule, intussusception in very young children is not attended by 
the great distension and marked sj^mptoms of general peritonitis which 
frequently appear in intestinal obstruction in adults. In children over 
two j^ears of age, the abdominal symptoms are more apt to indicate peri- 
tonitis. In a considerable proportion of cases, tenesmus occurs and adds 
much to the suffering. It does not appear so early as the abdominal pain, 
and generally ceases a few days before death. 

Tumor. — It would appear natural that when a considerable intussus- 
ception has taken place, the knot formed at the point of obstruction 
should be readily detected through the abdominal walls. Aud yet the 
cases on record show that this tumor is recognizable in not more than two 
or three out of every ten cases. When it can be detected, it is generally 
found in the left iliac region, vaiying in size from a walnut to a large 
goose-egg, and giving the sensation of a solid, but doughy and compres- 
sible mass. It is ordinarily quite movable, and percussion elicits a dull 
note over its position. 

Another symptom depending upon the displacement of the intestine, 
to which considerable importance has been attached in the diagnosis of 
invagination in the adult, is a depression of the abdomen at a point corre- 
sponding to the displaced intestine, and a fulness at the corresponding 
point on the opposite side. Experience has shown, however, that but 
little value can be attached to this sign in young children, on account of 
its great rarity. 

We have seen that the presence of a tumor in the abdomen is far from 
an invariable sign of intussusception, and the same remark applies to the 
protrusion of the invaginated bowel from the anus, a S3 T inptom to which 
very different diagnostic value has been attached \>y different authors. 
It is stated by some to be almost never present, but we have found it re- 



SYMPTOMS — DURATION. 427 

corded particularly in six of Smith's cases, the same number in which an 
abdominal tumor was present in the same series; and in three other 
cases, although no tumor protruded from the anus, the invaginated mass 
was readily felt by examination per rectum. 

When the bowel protrudes, it forms an oblong tumor, at times even two 
inches in length, much congested from the constriction, and smeared with 
blood and mucus. 

When we pass from these positively diagnostic s3 T mptoms, we find little 
elsewhere characteristic of the disease. The tongue is normal until in- 
flammatory action sets in, when it often becomes dry and brown ; the 
appetite is impaired or absent, and the thirst is generally but moderate. 
Rilliet and Barthez call attention to the importance of this last symptom 
in a diagnostic point of view, as well as to the fact that the emaciation 
is usually not so marked as in other acute diseases of equal duration and 
severity. 

The amount of febrile action is generally slight in infancy ; the sur- 
face, cool at first, ma}^ at times become hot, or is alternately hot and cold, 
and as death approaches remains continuously cold. The pulse soon be- 
comes frequent, though small and feeble. There is no marked disturb- 
ance of respiration. 

In older children there is apt to be more febrile action, the skin being 
hot until late in the attack, and the pulse frequent and more full. The 
physiognomy of the little patient is greatly altered from the commence- 
ment of the attack. The e} T es are dull and languid, sunken in their or- 
bits, and surrounded by discolored areolae ; the countenance is expressive 
of the most profound prostration, so as to have elicited a comparison to 
the physiognomy of cholera patients. 

Almost all cases, at whatever age, present symptoms of marked dis- 
turbance of the nervous s} T stem, as great restlessness, indescribable ma- 
laise, sharp cries, and, toward the close of the case, profound prostration. 
But in infancy, in addition to these sj^mptoms, the case is more apt to 
present an attack of convulsions, either as one of the earliest symptoms, 
or toward death, alternating with coma. 

Duration. — It is necessary to distinguish here between cases occurring 
during extreme infancy, when we cannot hope for elimination to take 
place, and those in more advanced childhood. In early infancy, when the 
attack is about to take a favorable turn, the symptoms usually yield in 
from two to four clays, owing to reduction of the invagination. In fatal 
cases, death occurs within five days, as the rule. In some cases, however, 
where the constriction was not complete, life has been prolonged even for 
six weeks. 

In second infancy, where the constriction is complete, and the result 
fatal, death occurs within seven or eight days in the vast majority of 
cases. But when elimination is to result, the case is more protracted, 
and complete recovery is postponed to the third week. Thus, in T cases 
out of Smith's statistics, which resulted favorably by sloughing, the ages 
were 5, 6, 6, 9, 11, 12, and 12 years respectively; and the separation of 
the invaginated portion took place between the ninth and twelfth days, 



428 INTUSSUSCEPTION. 

with an average of nine and a half daj^s. After the discharge of this, 
which is soon followed by the fetid, brownish-black stools already de- 
scribed, the symptoms rapidly disappear, and in one or two weeks the 
cure is complete ; so that, if we can carry a patient, advanced beyond the 
first infancy, through the first week of the attack without too much ex- 
haustion, we may each day look for the discharge of the invaginated 
bowel, the restoration of the function of the intestines, and ultimate re- 
covery. 

Terminations. — We have already described the favorable modes of ter- 
mination, namely, by the subsidence of the intussusception, either spon- 
taneously or as the result of treatment ; by restoration of the calibre of 
the bowel by sloughing of the invaginated bowel, and union and cicatriza- 
tion of the divided edges ; and finally, by agglutination of the outer 
layers of the invaginated portion with subsequent thinning and atrophy, 
thus rendering the intestine pervious, although the intussusception re- 
mains. 

In those cases in which death takes place very early, as on the first or 
second day, it is frequently produced by cerebral congestion or an attack 
of convulsions. In the majority of cases, however, it occurs somewhat 
later, and is preceded by a state of collapse. Even in those cases where 
the constriction is not at first complete, and where there are daily fecu- 
lent evacuations for a time, death is apt to occur from exhaustion, or 
from the invagination becoming more extensive and symptoms of com- 
plete obstruction arising. 

Prognosis. — A single glance at the character of the lesion and the ac- 
companying phenomena, suffices to assure us of the grave nature of intus- 
susception, and of the impotence of all ordinary methods of treatment 
against it. In young infants, indeed, where the strength of the s} T stem 
cannot be expected to hold out until elimination occurs, intussusception 
is almost invariably fatal. In a single instance only has recovery by 
elimination been noticed so early as the end of the first year. In a few 
cases, where the S3^mptoms were well developed and threatening, they 
have subsided and the infant has recovered, apparently from spontaneous 
reduction of the invagination. 

We must not, however, forget that during the early stage of this affec- 
tion the diagnosis is somewhat doubtful, since young children frequently 
present symptoms of obstructed and loaded intestine, such as a distended, 
hard abdomen, constant unnatural straining, with evident suffering, and 
yet are entirely relieved after the administration and operation of laxa- 
tives. 

A few cases of cure of undoubted intussusception, by means of infla- 
tion, have also been reported even at this early age ; so that, when treat- 
ment is instituted soon after the appearance of the sj^mptoms, the case 
is not absolutely hopeless. In older children, that is to say, above three 
3 T ears of age, the prognosis is much less unfavorable, since treatment 
offers a certain amount of hope, and there is alwa} T s the prospect of the 
occurrence of elimination of the invaginated bowel, if the strength of the 
patient has been sustained during the first week. 



DIAGNOSIS. 429 

Even after elimination has taken place, however, the prognosis should 
still be somewhat guarded, as the slightest indiscretion in diet may, either 
by the development of flatulence or by the escape of irritating, undigested 
particles into the intestine, cause a rupture of the recently formed cicatrix 
and speed}- death. 

Diagnosis. — Intussusception has been, until recently, regarded by all 
authors as an affection of obscure and doubtful diagnosis. With the 
light, however, which has been thrown upon this subject by the labors of 
Clarke, Gorham, Smith, and especially Rilliet, the diagnosis in the great 
majority of cases can be made with precision. It is true, however, as 
conceded by Rilliet, that " very rarely in early infancy, more frequently 
than later, there are certain cases of invagination impossible to dis- 
tinguish from other forms of intestinal obstruction ; and that at all pe- 
riods of childhood the diagnosis presents many difficulties." 

With what diseases, then, could we confound this affection, occurring, 
as we have seen, suddenly in perfect health ; attended by obstinate, 
though rarely fecal vomiting; by marked constipation, but with frequent 
bloody discharges ; by paroxysmal abdominal pain and tenesmus ; by the 
presence of a tumor, generally in the left iliac region ; by the protrusion 
of the invaginated bowel from the anus ; and by profound prostration and 
disturbance of the nervous system. It is to be remembered, indeed, that 
this group of symptoms, so characteristic when viewed together, are 
rarely all present ; and that, with the exception of the vomiting, consti- 
pation, and blood}- discharges, there is no single symptom which is not 
more frequently absent than present. There are, nevertheless, a suffi- 
cient number present in nearly every case to enable us to form a diag- 
nosis. 

The diseases which may most readily be confounded with intussuscep- 
tion are, 1st, impaction of the intestine with hardened faeces ; 2d, typh- 
litis or perityphlitis; 3d, cholera infantum; 4th, dysentery; 5th, intestinal 
hemorrhage ; 6th, the various forms of internal strangulation ; tth, peri- 
tonitis. 

1st. When an accumulation of fecal matter takes place in either the 
coecum or sigmoid flexure, the case may present many symptoms similar 
to those of intussusception. There is frequently such gastric and intes- 
tinal irritation, as to lead to occasional vomiting and paroxysmal ab- 
dominal pain ; the bowels are constipated, and there is frequent and 
strong tenesmus, so as often to cause protrusion of the bowel. In addi- 
tion to these symptoms, a well-defined tumor is present in one or the other 
iliac fossa. 

These. cases, however, often have presented symptoms of intestinal dis- 
turbance for some time previous to the attack ; the vomiting is rarely so 
constant as in intussusception ; the tumor is quite painless and has a 
peculiar doughy consistence ; bloody discharges from the bowels are very 
rare ; and we do not notice the profound prostration which exists in well- 
established invagination. During the early stage of the case, however, 
the diagnosis is doubtful ; and when we have reason to suspect the pres- 
ence of fecal accumulations, we must await the result of the administration 



430 INTUSSUSCEPTION. 

of laxatives and laxative enemata, before deciding upon the nature of the 
case. 

2d. Inflammation of the coecum, appendix vermiformis, or of the peri 
coecal connective tissue, is attended with fulness or a well-defined tumor 
in the right iliac fossa, with vomiting, constipation, and occasionally ten- 
esmus, with distension of the abdomen and pain radiating from the right 
iliac region. 

There is, however, a marked degree of fever, and the symptoms of local 
peritonitis appear early in the case ; the patient assumes a characteristic* 
position, with the thighs flexed upon the pelvis, and the right iliac fossa 
is the seat of exquisite tenderness, so that the slightest pressure cannot 
be tolerated. The vomiting and constipation are not so marked and obsti- 
nate, and excepting in those cases which have been preceded by dysen- 
teric s}'mptoms, there are no bloocty discharges, and, as we have remarked 
above, the tumor or fulness is in the right iliac fossa ; whereas, when this 
sign is present in intussusception, it usually occupies the left iliac region. 

3d. In cholera infantum, the vomiting is often incessant ; the stools 
are frequent, with painful tenesmus ; the abdominal pain paroxj-smal, and 
occasionally the intestine protrudes from the anus. It is almost im- 
possible, however, to mistake this affection for intussusception, if we re- 
member that it is almost always accompanied bj r fever, with insatiate 
thirst, and prompt and extreme emaciation ; that the abdomen is without 
tumor, and rarely distended until towards the close of the case, and that 
the stools, instead of being blood} T , are large and fluid. 

4th. Dysentery frequently offers a close resemblance to intussuscep- 
tion so far as the characters of the stools are concerned, as the}^ are often 
small and bloody, or muco-sanguinolent. But we do not see in dysentery 
the sudden inception, the rapid progress, the obstinate vomiting, the 
moist tongue and moderate thirst, which characterize intussusception. 

5th. We have seen that occasionally the amount of blood passed by 
stool in intussusception is very great, and constitutes a true intestinal 
hemorrhage ; thus in the case reported by Marwick, 1 it amounted to a 
large teacupful of pure blood. 

Intestinal hemorrhage is a very rare occurrence during childhood, but 
has been noticed in children in connection with polypus of the rectum, 
especially by Mr. Biyant ; in t} T phoid fever, or the hemorrhagic form of 
some others of the exanthemata, and in the course of purpura. The 
absence of the other s} T mptoms of intussusception, however, and the 
presence of the local or general symptoms peculiar to these various con- 
ditions, will serve to render the diagnosis easy. 

6th. Other forms of internal strangulation, such as those produced by 
a diverticulum from the intestine compressing it, by the adhesion of the 
vermiform appendix so as to constrict the bowel, or by a contraction of 
the calibre of the bowel, produce symptoms so identical with those of in- 
tussusception in second infancy, when the affection more nearly resembles 
intestinal obstruction in the adult, as to render diagnosis impossible. The 

1 London Lancet, July, 1846. 



TREATMENT. 431 

presence of an abdominal tumor, the occurrence of bloody stools, or the 
protrusion of the constricted bowel from the anus, would be the only 
diagnostic signs. 

7th. Peritonitis, when diffuse, presents a few symptoms in common 
with intussusception ; as the vomiting, constipation, abdominal pain and 
tenderness ; and when the inflammation of the peritoneum is localized, 
there is in addition a well-defined sensitive tumor, which soon appears 
as the result of the inflammatoiy action. The diagnosis here rests upon 
the greater frequency of the vomiting in intussusception, the more ob- 
stinate constipation with bloody discharges from the bowels ; the par- 
ox^'smal nature of the abdominal pain, with less tenderness ; the less 
degree of fever, the moist tongue, slight thirst, quiet respiration, and only 
moderately accelerated pulse. 

Treatment. — There is no special plan of treatment for intussusception 
deserving the name of preventive, owing to our ignorance of any symp- 
toms which can be definitely regarded as the precursors of the invagina- 
tion. The fact, however, that various derangements of digestion, such 
as pain upon going to stool, diarrhoea, or constipation alternating with 
diarrhoea, have been occasionally noticed to precede the attack, should 
be an additional motive to urge us to meet these symptoms by the most 
assiduous attention to the lrygiene of the child, and to the regulation of 
its alimentary functions. 

The curative treatment ma} T be divided into three classes : the medical, 
mechanical, and surgical treatment. 

Medical. — Depletion is strongly contraindicated by the tender age of 
the patients, and by the necessity of preserving the vital powers ; since 
elimination, which affords the principal chance of recovery, does not 
occur until after the eighth day. In order, however, to relieve the en- 
gorgement at the point of constriction, without reducing the strength of 
the patient, it is advisable to apply a few leeches or cups to the abdomen, 
and preferably to the right iliac region, unless a tumor can be detected, 
when, of course, they should be applied over its seat. 

Purgatives were formerly strongly advocated by most authors ; the one 
most generally advised being quicksilver, which was given with a view 
of overcoming the obstruction by its great weight and fluidity. The use 
of this agent is now, however, universally reprobated. 

In regard to other and less mechanical purgatives, there is still some 
difference of opinion. 

During the early stage of the attack, before the symptoms of intussuscep- 
tion are very positively developed, we should advise the administration of 
a mild but thorough laxative, such as castor oil, in conjunction with large 
laxative enemata. If, however, at the end of twenty-four or forty-eight 
hours, the administration of these remedies, aided by the local depletion, 
has failed to produce an evacuation from the upper bowel, these measures 
should be abandoned, and recourse be had to means of calming pain and 
nervous disturbance, and to the sustentation of our patient. Among the 
remedies best calculated to allay the pain, the tenesmus and the nervous 
irritability are : opium, in doses proportionate to the intensity of the 



432 INTUSSUSCEPTION. 

pain ; warm anodjme poultices applied to the abdomen, and warm baths 
carefully given. These latter are especially serviceable when the symp- 
toms of nervous disturbance are marked, even amounting, as the} r occa- 
sionally do, to general convulsions. 

In endeavoring to sustain the child's strength, attention must be paid 
to the vomiting, which is generally so severe as to prevent any nourish- 
ment being retained. The remedies of most service against this are 
counter-irritants to the epigastrium, opium, hydrocyanic acid, small pieces 
of ice kept constantly in the mouth or swallowed whole. 

Nutritious enemata may also be tried, but are rarely retained. 

The mechanical treatment consists in the injection of fluids or air into 
the bowel in such quantities as to distend it, and in the introduction of 
a large sound, with the view of pushing up the invaginated portion of in- 
testine. The fluids generally used have been either tepid water or warm 
gruel, injected forcibly into the bowel, until the sudden cessation of re- 
sistance informs us of the reduction of the intestine. We have already 
seen that the seat of intussusception in the child is almost invariably the 
lower end of the ileum, which passes into the ccecum and is there con- 
stricted ; and, when we reflect that it has been frequently demonstrated 
that if fluid be forcibly injected into the large bowel, the ileo-ccecal valve 
will rupture before any fluid is allowed to pass into the ileum, it is evi- 
dent that we can in this way exert a most powerful pressure upon the 
invaginated intestine. Experience shows that this procedure is fre- 
quently successful, even in cases where all medicinal treatment has proved 
unavailing ; and there are now a sufficient number of such cases on 
record, to render a resort to it proper. 

Air, however, both on account of its greater elasticit}^ and mobility, 
as well as the greater facility for its introduction in sufficient quantity, is 
to be even more highly recommended. Indeed, inflation was advised by 
Hippocrates as a remedy in intussusception, but until within the past forty 
years does not seem to have been much practised. Two cases of obstruc- 
tion of the bowels, occurring in adults, successfully treated by inflation, 
are reported in the American Journal of Medical Sciences, for 1833 : 
one by Dr. Janeway, of New York; the other, which, however, was tran- 
scribed from the Glasgow Medical Journal for 1831, by Dr. King. The 
following year, in the Boston Medical and Surgical Journal, December 
15th, 1834, Dr. J. Wood published a case, also in an adult, where death 
seemed imminent, but where the obstruction was readily overcome by in- 
flation, and the patient recovered. Since then, this remedy has been 
frequently employed in intussusception in children, and with such good 
results that it ma} T fairly be said that the prognosis of this affection is 
less grave since the introduction of this remedial measure. To obtain the 
best results, inflation should be employed early in the case, before any 
considerable amount of adhesive inflammation has taken place between 
the sheath and the contained intestine. The air is readily introduced 
by a pair of ordinary bellows ; the nozzle being inserted well into the 
rectum, and inflation continued until the obstruction yields. The re- 
turn of the invaginated intestine is sometimes attended b} r a clearly 



TREATMENT. 433 

audible sound, a species of crack, but it never gives any pain, and has 
generally seemed to afford relief. The complete restoration of the calibre 
of the intestine is proved by the copious feculent stools which frequently 
come away soon after the inflation. 

A third mechanical means for restoring the displaced intestine has 
been recommended by Dr. Nissen, and consists in pushing up the invagi- 
nated portion by means of a oesophageal sound protected by a sponge. 
This proceeding would probably be readily accomplished, if the intus- 
susception occurred far down in the large intestine ; but it would appear 
very difficult to replace an invagination as high as the ileo-ccecal valve. 
Dr. Nissen, however (in the Journal de Constatt, quoted by Rilliet and 
Barthez), gives two cases in which he succeeded in pushing up the intes- 
tine into the ascending colon, with complete relief of the symptoms of 
obstruction. There are also a few other cases of cure, by this means, 
upon record in medical literature. 

The surgical treatment consists in the performance of the operation of 
gastrotonry, finding the invaginated portion of bowel and reducing it by 
gentle traction. Opinions differ greatly as to the propriety of this opera- 
tion in intussusception. The majority of authors, especially the English 
and American ones, however, seem to condemn it. They base their unfa- 
vorable opinion upon the grounds of the great difficulty of ascertaining 
the exact position of the intussusception ; the difficulty of restoring the 
invaginated intestine even if found; and finally upon the dangers of the 
operation. 

TVe have seen, however, that in the majority of cases the invaginated 
mass will be found in the neighborhood of the left iliac fossa ; the lower 
end of the ileum having traversed the ccecum, ascending and transverse 
colon, and these parts being successively inverted ; that in a certain pro- 
portion of cases a tumor is readily detectible ; and further, that some 
idea as to the seat of obstruction may be obtained from the distance to 
which enemata appear to penetrate. So that in a considerable proportion 
of the cases, we have the means of localizing the point of constriction, 
with a certain amount of definiteness. 

In regard to the difficulty of reducing the invaginated parts, authors 
differ greatly. It has been remarked, that even if the equivocal and uncer- 
tain nature of the symptoms of volvulus were not sufficient to deter us 
from undertaking the operation, the state of the invaginated parts would 
entirely banish all thoughts of such an imprudent attempt ; since the dif- 
ferent folds of intestine become so agglutinated to each other that they 
can hardly be withdrawn, even after death. 

Rilliet and Barthez (loc. cit.), however, conclude from their anatomical 
researches, that in the majority of cases the disengagement of the intes- 
tines is very easily accomplished ; and accordingly they declare that, 
" after employing medical treatment during three or four da} T s, and after 
having made several attempts at inflation, we should not hesitate to per- 
form gastrotomy." 

The great danger of the operation is, of course, apparent, but should 
hardly be considered an objection, when we consider the fatal nature of 

28 



434 INTUSSUSCEPTION. 

this affection. Nor have the results of operation "been such as to destroy 
hope ; for in addition to several successful operations previously recorded, 
the only 3 cases of the 57 collected by Haven, in which gastrotomy was 
performed, terminated favorably. 

To sum up our remarks upon this subject : after having tried for two 
or three days the medical and mechanical means recommended, without 
success, we must forbear and decide whether to trust the case to nature, 
with the hope of elimination of the invaginated bowel occurring, or to 
resort to gastrotomy. And in this decision, the circumstances of each 
case must be taken into account ; for if the case has not yet progressed 
so far that adhesive inflammation has certainly taken place, and if we are 
able to detect the exact seat of constriction by the presence of a tumor, 
the operation certainly has strong arguments in its favor, and should not 
be hastily rejected. 

In those cases which have been trusted to nature, and when elimina- 
tion has fortunately occurred, we must treat the child, during this crisis, 
with the utmost care. The diet must be rigidly regulated, and the child 
kept in absolute repose. Nor must we relax these precautions for several 
weeks, and allow either indigestible food, or too large a meal of even the 
most digestible articles ; since death has been several times known to 
follow this imprudence, from a rupture of the imperfectly formed cica- 
trix. 



CLASS IV. 

DISEASES OF THE NERVOUS SYSTEM. 

GENERAL REMARKS. 

It is a very common opinion, both in and out of the medical profession, 
that this class of diseases occasions a much larger number of deaths in 
childhood than any other. Indeed, many persons suppose that, be the 
primary disease what it may, nearly all children who die, die as it is said 
by the brain. It appears, however, from an examination of the bills of 
mortalhVv for this cny, that this opinion is not well founded. During the 
five years from 1844 to 1848 inclusive, the number of deaths from dis- 
eases of the nervous S3 T stem was less than from diseases of the digestive 
system, and though larger than those from diseases of the respiratory 
organs, not so much so as the popular notion would seem to warrant. 
The number of deaths from diseases of the nervous system was 3910; 
from diseases of the digestive S3 r stem, 4204 ; and from affections of the 
respiratory sj^stem, 3316. M. Barrier, whose observations were made at 
the Children's Hospital in Paris, says (loc. cit., t. i, p. 35) that, setting 
aside cases in which the nervous symptoms were probably only sympa- 
thetic of some other coincident disease, the cerebro-spinal affections were 
few in number in comparison with those of the thorax, abdomen, and 
senses, including amongst the latter the eruptive fevers. He states (loc. 
c?Y.,p. 34) that affections of the thorax constituted two-fifths of all the cases 
of disease, those of the abdomen and senses each one-fifth, and of the 
nervous centres only a tenth. M. Barrier, after combating the opinion so 
generally entertained, that disorders of the nervous system cause the 
death of the greater part of the subjects who die before puberty, says 
(loc. cit., t. ii, p. 233) that there is only one circumstance that in part 
justifies this opinion, which he opposes "not as false, but as exaggerated," 
and this is, that the affections alluded to are almost always of a danger- 
ous character, that they are beyond the resources of art, and that they 
furnish a very considerable relative mortality. He says that, according 
to his experience, the mortality in diseases of the cerebro-spinal S3'stem 
has been as sixty-eight in a hundred, while in those of the thorax, senses 
(including the skin), and abdomen, it was respectively as forty-eight, 
forty, and thiHy-two in a hundred. 

Before beginning the consideration of the particular diseases of this 
class, we are desirous of stating that we shall be compelled, on account of 
our limited space, to devote attention chiefly to those which are most im- 
portant from their frequency or severity, avoiding or merely alluding to 



436 TUBERCULAR MENINGITIS. 

those which are of less consequence, or which occur in childhood merely 
in common with adult life. 

In our last edition we divided this subject into two classes, one con- 
taining all the diseases attended with and dependent upon, some appre- 
ciable alteration of the nervous centres, the second containing those in 
which no such alteration exists. TVe have, in the present edition, dis- 
carded that arrangement, principally on account of the minute researches 
of histologists during the past few years, which have all gone to prove 
the existence of positive and definite tissue changes in many diseases 
previously regarded as purely functional. 



AETICLE I. 



TUBERCULAR MENINGITIS. 



Definition ; Symptoms ; Frequency. — This disease is characterized by 
violent cerebral sj-mptoms, dependent upon the existence of tubercular 
granulations in the pia mater, as the essential anatomical lesion ; accom- 
panied, in the great majority of cases, by coincident inflammation of that 
membrane, by softening of the central parts of the brain, by effusions of 
serum into the ventricles, and in many instances by tubercular deposits 
in other organs. Formerfv tubercular meningitis, simple acute meningitis 
independent of tuberculization, and simple dropsical effusion within the 
cavity of the cranium independent of inflammation, were confounded to- 
gether under the single term of acute hydrocephalus or water on the brain. 
It has been shown, however, that a large majority of the cases of acute 
Irydrocephalus of authors are, in fact, cases of tubercular meningitis, and 
more recent researches have further shown that most of the remaining 
cases are in realit}^ due to the altered condition of the blood, called 
uraemia, and are independent either of any material lesion of the brain 
or of the presence of an excess of serous fluid in its cavities. 

The term acute t^-drocephalus ought to be therefore restricted to the 
single condition of sudden serous effusion in or around the brain, inde- 
pendent of any inflammation ; a condition which only occurs in connec- 
tion with the causes of general dropsy, and especially with renal disease, 
and is, indeed, merely the most rare form of internal dropsy, and, as such, 
not to be regarded as a separate disease. A description of the symp- 
toms of this condition will be found in our remarks upon the renal com- 
plication of scarlatina. 

There can be no doubt that tubercular meningitis is of rather frequent 
occurrence, though we are acquainted with no statistics excepting those 
given by M. Barrier (loc. ciY., t. i, p. 34, 36), which will enable us to form 
an}*thing like an accurate idea upon this point. That author states that 
during the period in which his observations were carried on at the Chil- 
dren's Hospital in Paris, there occurred 5T6 medical cases of all kinds. 



PREDISPOSING CAUSES. 437 

In this number there were only ten cases of tubercular meningitis, whilst 
there were 83 of pneumonia, 48 of pleurisy, 24 of typhoid fever, 48 of 
measles, etc., etc., showing the first-named disease to be much less fre- 
quent than many other affections. We may also form some idea of its 
frequency in proportion to other diseases, by a reference to the work of 
MM. Rilliet and Barthez (lere edit.), who report 33 cases of tubercular 
meningitis, against somewhat over 245 of pneumonia, 174 of bronchitis, 
111 of typhoid fever, 167 of measles, and 87 of scarlet fever. We are of 
opinion that it is not of frequent occurrence amongst the easier classes 
of this city, since we have met with only 31 cases in private practice in 
the course of twenty-five years. From what we have been told by other 
practitioners, however, it seems probable that it is much more common 
amongst the destitute classes, and particularly the blacks, who crowd 
the southern parts of the city, and who suffer to a great extent from 
tubercular and scrofulous diseases. It is, however, impossible to obtain 
accurate information in regard to the frequency of the disease in this 
city, in comparison with other affections of the brain, from a reference to 
the bills of mortality, because of the fact that all or nearly all these affec- 
tions are returned under the titles of dropsy and inflammation of the 
brain. 

Predisposing Causes. — MM. Rilliet and Barthez (2eme edit., t. iii, p. 
511) state that the disease is very rare in the first year of life; that it 
becomes notably more frequent in the second year, but that it is between 
two and seven years of age that it occurs with the greatest frequency. 
After this it diminishes, they say, rapidly from eight to ten, and espe- 
cially from eleven to fifteen years of age. The influence of sex has not 
been determined, but it appears probable that boys are somewhat more 
subject to it than girls. It has been clearly shown by the observation of 
various writers that the disease usually attacks delicate children, and es- 
pecially those born of parents who are either themselves laboring under 
tuberculosis, or in whose families that diathesis has existed to a greater 
or less extent. Of the 31 cases that have come under our own observa- 
tion, in 20, one of the parents either had phthisis at the time, or died of 
it subsequently ; in 3, one or the other parent came of a tuberculous 
family, though in these both parents were living at the time in seeming 
good health ; in 4, no trace of tuberculosis could be found in the parents 
or in their families, and in 4 the history of the parents and of their fami- 
lies could not be traced out. It is not uncommon for several children in 
a family to die of tubercular meningitis. Under these circumstances, it 
has nearly always been ascertained that the parents, or some of the imme- 
diate relations, have either died of tuberculous or scrofulous disease, or 
shown unequivocal signs of that diathesis. Thus, 4 of the above-men- 
tioned 20 cases occurred in two families, in one of which the father is 
since dead of phthisis, and in the other the mother has long been ailing 
with inactive tubercle of the lungs, and slow caries of a bone, in all prob- 
ability of tuberculous origin. It may follow other diseases, and has been 
observed particularly after measles and other fevers, and after the sup- 
pression of eruptions. 



438 TUBERCULAR MENINGITIS. 

M. Barrier (op. cit.,t. ii, p. 379) explains, and we think with good show 
of reason, the causes of the disposition on the part of the tubercular dia- 
thesis in children to localize itself in the brain, as well as the dispropor- 
tionate violence and extent of the inflammatory action in proportion to 
the degree of the tubercular lesion, by the physiological conditions of the 
nervous s}'stem in early life, which are those of great functional energy 
and nutritive activity. 

As to the exciting causes, nothing positive is known. The disease has 
been supposed to be brought into action by falls and blows upon the head, 
by violent moral emotions, and by exposure to the sun. These causes, 
however, are all of doubtful influence. 

Anatomical Lesions. — The tubercles which constitute the essential 
anatomical element of the disease are very rarely found upon the free 
surface of the arachnoid, but almost invariably beneath that tissue, or in 
the meshes of the pia mater. They usualty appear as more or less opaque 
gray granulations, the so-called miliary tubercles, and may generally be 
seen through the arachnoid, scattered about in the shape of small, 
rounded, or flattened bodies, of grayish or yellowish-gray color, and 
vaiying in size from two-fifths to four-fifths of a line. When the finger 
is passed over the arachnoid above them, the} 7 may be usually felt as little 
granular bodies. Their size, however, varies very much, and the} 7- are in 
some cases so small and so closely resemble in color the surrounding 
parts, that it requires a careful search to detect them. Thej' vary also 
greatly in number, being in some cases thickly scattered over a consider- 
able extent of the pia mater, while in other cases but two or three can be 
discovered on each hemisphere. 

Frequently they can be detected with most ease upon the processes of 
pia mater which dip down between the convolutions, so that if we fail 
to find any granulations upon the surface, we should always strip off the 
pia mater and carefully examine these processes. Upon a careful exami- 
nation of the arrangement of the miliary tubercles, it will often be ob- 
served that they are clustered about the small arterioles of the pia mater, 
and evidently follow in their distribution the branches of these vessels. 

These granulations are not found upon all portions of the brain equally 
in cases of tubercular meningitis. On the contrary, they are rarely pres- 
ent upon its convexity or lateral aspects, while they are uniformly present 
at the base, and especially about the optic chiasm and the fissures of 
Sylvius. 

Upon microscopic examination of one of these granulations, its tissue 
is seen to be composed of numerous oval cells with a single nucleus, 
though there are also some larger cells mixed with these which contain 
several nuclei. In many instances, as has been observed by Cornil, 1 
Hayem, 3 Bastian, 3 and ourselves, 4 the tuberculous granulation will be 
seen to envelop a small arteriole, whose calibre is obstructed at the point 

i Arch, de Phys. Norm, et Path., 1868, p. 98. 

2 Etudes sur les Diverses Formes d'Encephalite, Paris, 1869. 

3 Edin. Medical Journal, 1867, p. 875. 

4 Traus. of Biological and Micros. Section of Acad, of Nat. Sci. of Phila., 1869. 



ANATOMICAL LESIONS. 439 

of its development. There is also marked proliferation of the cells of 
the peri-vascular sheath of the vessel for a varying distance on either 
side of the granulation, and it is highly probable that it is from these 
cells that the granulation has been developed. 

We think it probable that some of the granulations may also be devel- 
oped from the cells of the connective tissue, which holds together the 
vessels of the pia mater. 

These miliaiy tubercles precede the occurrence of the inflammatory 
changes in the meninges described below, and sometimes it happens, in 
veiy acute cases, that the only lesions discoverable consist of a few gray 
granulations scattered in the meshes of the pia mater. It is not prob- 
able, however, that they exist any great length of time without giving 
rise to meningitis, since the} T are usually found associated with more or 
less abundant inflammatory exudation, which surrounds and often con- 
ceals them. The chief seat of this inflammation, as of the tubercular 
deposition, is the pia mater; the arachnoid membrane being, as a general 
rule, affected only to a slight extent. That membrane sometimes, how- 
ever, contains a very small quantity of clear or turbid serum in its cavity. 
Its surface is often dry and viscid, and in some instances its whole tissue 
is opaque and thickened. But it is chiefly in the pia mater that are 
found the evidences of severe inflammation. In order to detect these 
changes, it is necessary to examine the membrane not merely upon the 
surface of the brain, but to tear it off, so as to bring into view the por- 
tions which dip in between the convolutions, and which often exhibit the 
greatest amount of morbid alteration. The inflammatory lesions vary be- 
tween mere vascular injection, infiltration with clear, turbid, or gelatinous 
liquid, and abundant formation of lymph. When the inflammation has 
gone beyond mere sanguine injection, it is marked by infiltration of the 
membrane with turbid, whitish, or sanguinolent serum, with pus, or with 
whitish or 3 T ellowish lymph. These products are, like the tubercular 
granulations which they imbed and often conceal, most abundant at the 
base of the brain, about the peduncles of the cerebrum, the optic chiasm, 
and in the fissures of S3 T lvius. In this respect the disease differs from 
simple meningitis, in which the results of inflammation are usually more 
abundant and well marked upon the convexity than at the base. The pia 
mater, which, in a healthy brain, can be readily detached from the sur- 
face of that organ, becomes, in cases of meningitis, particularly those 
which are violent, more or less adherent, so that in tearing it off portions 
of the cineritious substance, which is itself softened, come with it. The 
proper tissue of the membrane is thickened and indurated, the degree of 
thickening depending on the amount of infiltration. 

After the changes in the pia mater, the most important anatomical fea- 
ture is effusion within the ventricles. This w T as formerly thought to be 
the essential lesion of the disease, but recent researches have shown that 
it is absent in some instances which have followed in all respects the ordi- 
nary course of the malady. According to M. Barrier, effusion cannot be 
supposed to exist unless the ventricles contain from one and a half to 
two ounces of fluid, whilst Rilliet and Barthez assert that the normal 



440 TUBERCULAR MENINGITIS. 

quantity is a few grammes (about a drachm). The quantity in this dis- 
ease is very variable ; sometimes there are only a few drops or a teaspoon- 
ful, while in other instances it amounts to three ounces and a half, or 
much more. It may be so large as greatly to distend the ventricles, 
rupture the soft commissure of the thalami, and even the septum lucidum, 
diminish considerably the thickness of the hemispheres, and flatten the 
convolutions against each other. In such cases the effused fluid passes 
through the membrane of the ventricle and infiltrates into and softens the 
substance of the brain, so that the latter becomes almost of the consist- 
ence of thick cream. The characters of the fluid vary in different cases. 
It is white, perfectly limpid and transparent, or may be turbid, either 
from being secreted in that condition, or from holding in suspension 
albuminous or purulent flocculi, or portions of the broken-down walls of 
the cavity. In some rare instances it is sero-sanguinolent. Bllliet and 
Barthez remark that the effusion which coincides with tubercular menin- 
gitis is different from that which accompanies tubercles of the substance 
of the brain. In the former it takes place rapidly, is turbid, exists in 
smaller quantity, and constitutes the condition formerly called acute hy- 
drocephalus. In the latter it is secreted slowly and in considerable quan- 
tity, dilates the walls of the cranium, and constitutes one form of chronic 
hydrocephalus. 

The brain itself presents various morbid alterations. The whole organ 
often seems enlarged, so that the dura mater appears distended, and when 
the latter is cut into, the cerebral substance protrudes in the form of a 
hernia. At the same time the convolutions are observed to be pressed 
against each other, and the anfractuosities seem to have disappeared. 
The compression of the brain depends either upon the distending action 
of the ventricular effusion, or upon sanguine turgescence of the organ. 
In most cases, but not in all, there is evident congestion of the cerebral 
substance, shown b} T a more or less abundant dotted redness, and some- 
times by a general rosy tint of the medullary, and vivid redness of the 
cortical portion. Softening of the substance of the brain is of common 
occurrence in connection with the other lesions. We have already spoken 
of the softening of the walls of the ventricles where there is much effusion, 
and which in some cases appears to result from the macerating influence 
of the fluid. In many other cases, however, microscopic examination of 
the softened brain-tissue shows the effects of inflammation in the presence 
of numerous granule-cells, free granular matter, and a disintegrated con- 
dition of the nerve-fibrils. The lining membrane' of the ventricles also 
presents abnormal appearances in a majority of cases. In some these 
consist merely in injection with loss of polish and transparenc}' ; in others, 
however, by viewing the surface sideways, we can detect a very finely 
granular condition, as though the membrane had been sprinkled with fine 
sand. Loschner (Aus clem Franz-Joseph Kinderspitale, 1860, Prague), has 
found this appearance to be due to a proliferation of the cells of the 
epencbvina, the minute granulations consisting of rounded nucleated cells. 
In Dr. West's minute analysis of 61 autopsies of tubercular meningitis, 
also, the lining membrane of the ventricles presented evidences of inflam- 



SYMPTOMS. 441 

mation in a large proportion of the casef.. We have also referred, very 
cursorily, to the softening which exists under the inflamed portions of the 
membranes, and which occasions adhesion of the pia mater to the brain 
beneath. In the latter cases the softening may be either red or white, 
and does not penetrate more than a line, and often less, in depth. 

In addition to the changes already described, tubercles of the brain 
itself may be occasionally met with, having no connection with the me- 
ninges. These are found in varions parts of the organ, and differ greatly 
in size, varying generally between that of a millet- seed and hazel-nut, but 
reaching sometimes the volume of a pigeon or hen's-egg, or even that of 
half the fist. 

TVe have but few words to say in regard to the lesions of other organs. 
It is undoubtedly true that in the vast majority of cases tubercles are 
found in other parts of the bod} 1 ". Of all the cases of tubercular disease 
observed b} T Rilliet and Barthez, amounting to 312, in only one was the 
deposit confined to the meninges (op. cit., lere edit., t. iii, note, p. 49). 
M. Yalleix (op. cit., t. ix, p. 196, 19t) states, that in all the cases, without 
exception, of tuberculosis of the meninges in adults, tubercles exist also 
in the lungs, and that the same is true, in the vast majority of cases, in 
regard to children. The organs in which the deposit is most apt to 
exist are the bronchial glands, lungs, mesenteric glands, pleura, and 
peritoneum. 

Another very frequent lesion is softening of the stomach. This may 
affect only the mucous or all the coats, so that a slight degree of force 
will suffice to tear the organ. Dr. Gerhard ( Am. Jour. Med. Sci., vol. 
xiv, 1834) states, that lesions of the stomach existed in six of the ten 
cases detailed by him, and in four-fifths of others not detailed. 

Before quitting this subject, we would call the attention of the reader 
to the fact mentioned by M. Yalleix (op. cit., t. ix, p. 214) that all the 
symptoms about to be described as constituting the disease under con- 
sideration, with the exception of paralysis, may depend on simple tuber- 
culosis of the meninges. Several cases have been cited, in fact, in which 
the only lesion found after death consisted of granulations in the pia 
mater. No traces of inflammation were observed. It is clear, therefore, 
that the evidences of the disease, or symptoms, depend not merely on in- 
flammation caused by the tubercular deposits, but on the presence of 
that morbid production. The paralysis, which is one of the important 
symptoms, is thought to depend chiefly on softening of the substance of 
the brain. The author referred to states that it occupies the side opposite 
that in which the change exists. 

Symptoms ; Course ; Duration. — The disease has been divided by 
authors into different stages, founded on the predominance of certain 
symptoms at particular periods of its course. 

These divisions are all imperfect and unsatisfactory, because the disease 
is in fact a continuous one, and for this reason some writers have avoided 
attempting any classification of the symptoms. We can, however, obtain 
a more faithful picture of the disorder by adopting the division made by 
M. Yalleix, which, though arbitrary and imperfect, because of the want 



442 TUBERCULAR MENINGITIS. 

of a natural line of demarcation, seems warranted by the very great dif- 
ferences in the character of the symptoms at an early and late period of 
the affection. We shall therefore describe first the invasion of the malady, 
and then two stages or periods of the sj^mptoms after the disease is con- 
firmed. 

The invasion of the disease may be either insidious or sudden. In a 
large majority of the cases, the onset is preceded by a well-marked pro- 
clromic period. The length of this period varies greatly in different sub- 
jects. Its duration is stated by MM. Rilliet and Barthez to be, as a 
general rule, between fifteen days and three months, scarcely ever less, 
and rarely more. During this period, the symptoms presented by the 
child are those which are usually held to be indicative of a failure in the 
general health. The nutritive functions especially show disorder. The 
appetite diminishes, or becomes capricious, there are alternations of con- 
stipation and diarrhoea, the body grows thin, the color pales, the g&yety 
of childhood disappears, and the patient becomes listless, apathetic, and 
complains of being tired and weak ; or he is irritable and peevish, or too 
mild and gentle ; study and exercise both become distasteful, and there 
is a degree of weakness and debility which, though slight at first, becomes 
at length so evident as to arouse the attention of the parents, or those who 
have charge of the child. Besides these symptoms, there is often very 
great restlessness at night. The only pain complained of is headache, 
and sometimes abdominal pain. The headache is, in subjects old enough 
to notice and describe their sensations, often a prominent symptom. It 
is not constant, but occurs at intervals, and is sometimes severe, and its 
returns frequent. Fever is not generally present until after the more posi- 
tive symptoms have fairly begun, and when present' is generally slight 
and fugacious. The emaciation and loss of strength are seldom present 
to such a degree, in the prodromic stage, as to confine the child to the 
house. On the contrary, he continues to amuse himself at times, and to 
walk as usual. 

The following is a rapid and summary account of the mode of invasion 
in the cases that have come under our own observation : 

In one case, in a girl six years of age, the invasion was preceded during 
three months by occasional cough, and irregular attacks of fever, b}^ pro- 
gressive emaciation, paleness, languor alternating with extreme irrita- 
bility, disinclination to take exercise, and during the latter part of the 
time b}^ partial lameness, and in fact by all the signs of general tubercular 
disease. In another, which occurred in a boy eight, years of age, it was 
preceded for several months by frequent complaints of intense headache, 
especially after taking active exercise, and by unusual languor, but no 
other symptoms. The boy was sent to a boarding-school apparently well, 
and was suddenly attacked there. In five cases the meningeal S3 T mptoms 
were developed in connection with those of phthisis, whilst in an eighth 
they followed a state of general weak health, with d}^speptic symptoms, 
which had lasted for several months. In a ninth case, a violent convulsion, 
seemingly dependent on a fit of indigestion, was followed during four 
months by irregular and diminished appetite, by some loss of strength and 



SYMPTOMS. 443 

flesh, and by frequent attacks of severe headache, and at the end of that 
time, by the symptoms which denote inflammation of the membranes. In 
a tenth, after some months of gradual thinning and general debility, a con- 
vulsion occurred, also from indigestion apparently. This was recovered 
from, but a few days afterwards the symptoms of meningitis showed them- 
selves, and followed their usual course. In an eleventh case, occurring in 
a girl ten j^ears of age, there was a mild, almost continuous fever, lasting 
four weeks, and resembling most closety typhoid fever, except that there 
was no diarrhoea and onl} r a very few doubtful rose spots, when severe 
frontal headache, vomiting, slow and intermittent pulse, with drowsiness, 
declared the invasion of tubercular meningitis. In a twelfth, a girl three 
years old, born of healthy living parents, presented for four days the 
signs of gastric catarrh, with, however, unusual irritability of temper al- 
ternating with a suspicious quiet. On the fifth day, there was just per- 
ceptible strabismus, after which the case went on in the usual way to a 
fatal result. In a thirteenth, in a girl five years old, of healthy living 
parents, but with tuberculous grandparents on the father's side, the gene- 
ral health failed slowly, with loss of appetite and flesh for one month. 
Then there set in lassitude, desire to lie about, with the most petulant 
irritability on the slightest disturbance, occasional vomiting, constipation, 
loathing of food, and gradual conversion of drowsiness into coma, and so 
on to the end. In the remaining cases that we have seen, the invasion 
was preceded by much less decided proclromic symptoms. 

After the different phenomena above described as characteristic of the 
proclromic stage have continued during a variable length of time, the 
disease enters into activity, a change which is ushered in by three im- 
portant symptoms: headache, vomiting, and constipation, to which is 
added, in a large majority of the cases, slight acceleration of the circula- 
tion. At the same time the intelligence remains perfect, the strength is 
not greatly diminished, the appetite is not entirely lost, and the thirst is 
moderate. 

First stage. — The headache, vomiting, and constipation persist and be- 
come more marked. Headache is a nearly invariable symptom in chil- 
dren old enough to describe their sensations, and is therefore very impor- 
tant. In infants its presence is to be inferred when the child carries its 
hands frequently to various parts of the head, and presses strongly against 
it, and when the head is constantly rolled from side to side. It is gene- 
rally frontal, and is usually referred to a point just over one or both brows. 
In other cases it extends over the whole head. It is commonly severe, 
so that the child when old enough complains of it spontaneously. In the 
case of a girl seven years old, whom we saw, it was so severe that she 
cried frequently and bitterly, begged to have the doctor sent for, and 
submitted willingly to any remedy suggested with a view to its relief. 
It is thought that the acute, shrill cry of the disease, to which the term 
hydrencephalic has been applied, depends on the acuteness of this pain. 
It usually lasts throughout the first stage, and ceases only as the delirium 
and coma of the second stage come on. Vomiting is also a nearly con- 
stant symptom. Of 80 cases collected from different sources by M. Bar- 



444 TUBERCULAR MENINGITIS. 

rier, it was absent only in 15, or less than a fifth. This symptom generally 
makes its appearance on the first clay, rarely later than the second or 
third, and lasts two or three da} T s, and sometimes longer. In one case 
that we saw, it lasted eleven days, though it was but slight on the tenth 
and eleventh. The matters ejected from the stomach consist of the in- 
gesta, and of mucus and bile in various proportions. It is commonly 
repeated two or three times a day. Constipation is even more important 
as a symptom than the one last named. Of SI cases it was absent only 
in 1, according to Barrier. MM. Rilliet and Barthez state, however, that 
it exists at the beginning only in about three-fourths of the cases. Where 
there is diarrhoea, instead of constipation, at the invasion, as sometimes 
happens, the former s} T mptom almost always depends on tubercular dis- 
ease of the intestine. Even under these circumstances, however, the 
diarrhoea is sometimes arrested, and constipation substituted under the 
influence of the cerebral disease. The constipation generally persists 
obstinately for several days, and then gives way under the influence of 
purgative medication, or is replaced spontaneously by diarrhoea with in- 
voluntary stools towards the termination of the case. 

In connection with the three important symptoms just described, there 
are others, which, though less characteristic, are of much assistance in 
forming the diagnosis. The child is dull and sad, or excited and irritable 
by turns; he shuns the light, or closes the eyelids and contracts the brows 
when it is thrown upon the face ; his hearing becomes painfully acute, so 
that sudden and jarring sounds distress and irritate him; the deep is 
restless and disturbed, and accompanied by grinding of the teeth; and 
he utters from time to time, both sleeping and waking, the peculiar shrill, 
sharp, and sudden scream, which seems to depend upon internal pain, 
probably headache, and which has been called hy Coindet the hydren- 
cephalic cry. In young children, those who have not yet learned to put 
their sensations into words, a peculiar, apparently causeless, obstinate 
peevishness and positive ill-temper, shown by sudden, sharp crying at 
anj^ disturbance, as even the kindness of a father or mother, especially 
when this alternates with sluggishness or drowsiness, and when there is 
no evident disease of a painful or exhausting kind to explain such a state, 
ought to arouse the fears of the physician as to the possible inception of 
this disease, even when there is as yet no vomiting or distinct signs of 
headache to call attention to the brain. The general as well as the special 
sensibilnVv, is sometimes, but not by any means always, exaggerated at 
this time. Rilliet and Barthez met with exaltation of this function only 
in four of their patients. The intellectual faculties remain undisturbed 
in the majority of the cases during the first few clays, and this fact, which 
is so contrary to what might be expected, is one of the utmost importance 
in the judgment of the case. We remember being asked by a little girl 
seven } r ears old, to whom we have alreadj^ referred, "wiry it was that she 
saw double; why she saw two mothers and two doctors?" At the time 
when she first asked the question there was no perceptible strabismus, 
but on the following day we thought we could detect a deviation of one 
of the eyes from its proper axis, and on the third day the deviation was 



SYMPTOMS OF THE FIRST STAGE. 445 

very marked, though the poor child still wondered why she saw two ob- 
jects instead of one. 1 In another case in a boy five years old, there was 
no disorder of the intelligence until the eleventh da}^ when there was 
slight delirium alternating with somnolence; yet it was clear from the 
first that the attack would prove one of tubercular meningitis, from the 
coexistence of violent frontal headache, obstinate vomiting, constipation, 
slow and irregular pulse, and the absence of other local or general symp- 
toms. In only a fifth of the cases observed by MM. Killiet and Barthez 
was there perversion of the intellectual faculties at the invasion. Let us 
observe, moreover, that even when children present some of these dis- 
orders early in the attack, they generally consist only of slight delirium, 
dulness of the intelligence, slowness and hesitation in answering ques- 
tions, disposition to somnolence, excessive irritability and peevishness 
of temper, and what is more important and characteristic than any of 
these, perhaps, of a certain expression of the countenance, and particu- 
larly of the look, which is expressive of astonishment or of the utmost in- 
difference. The look is, in fact, fixed or staring, like that of one in a 
mild ecstasy. Even when these symptoms exist, however, at an early 
period, the} 1 - not unfrequently alternate with the most perfect clearness 
of the faculties, so that the physician in private practice, who sees his 
patient only at long intervals, and for a few moments at a time, should 
never venture to disbelieve, without due consideration, the account of 
the mother or nurse as to their occasional presence during his absence, 
even though never observable during his visit. We knew this to happen 
in regard to two boys of eight and ten 3 T ears of age respectively, whose 
mothers constantly insisted to the physician in attendance that during 
his absence the children occasionally presented slight delirium, and a 
wild uncertain expression of the countenance, which made them fear that 
the brain might be affected. As the children's intelligence was perfect, 
however, whenever the doctor saw them, he determined that the mothers 
were fanciful through over-anxiety, and ascribed the sickness to a bilious 
disorder of the stomach. After a few days the cases developed themselves, 
and the boys died with every symptom of tubercular disease of the brain. 

1 Use of the Ophthalmoscope in Tubercular Meningitis. — In this disease, 
as in acute simple meningitis, the obstruction to the return of venous blood through 
the sinuses produces in both eyes, but especially in the one corresponding to the 
hemisphere where the inflammation is most intense, congestion and oedema of the 
optic papilla and surrounding tissue (Bouchut's peripapillary congestion); tortuosi- 
ties and varicosities of the retinal veins; and occasionally thrombosis or rupture of 
these vessels, causing minute hemorrhages in the retina. In some cases the size of 
the globe is increased, owing to hydrophthalmia. These lesions are indeed more 
frequent in this disease than in simple meningitis, since the inflammation and re- 
sulting exudation are more apt here to involve the base of the brain, and cause a 
greater degree of obstruction to the circulation. 

These retinal lesions cannot be regarded as pathognomonic of the existence of this 
disease, and are therefore only valuable as confirmatory of the general symptoms, 
save in certain cases where the development of the ocular lesions before the appear- 
ance of the more characteristic symptoms might enable the diagnosis to be made at 
an earlier date than would be possible without ophthalmoscopic examination. 



446 TUBERCULAR MENINGITIS. 

When disorders of intelligence do not occur in the early da3 T s of the 
attack, they usually make their appearance about or soon after the fifth 
day. 

During the first stage the coloration of the face ought to be noticed. 
It is generally paler than natural, though from time to time a sudden 
flush of redness may be seen to pass over it. The condition of the senses 
is natural, except that the acuteness of the eye, ear, and sometimes that 
of touch, are exalted, so that the child avoids the light, starts at sudden 
or loud sounds, and cries when it is touched or moved. The respiration 
becomes unequal and irregular, and is interrupted by sighing or y awning. 

Convulsions rarely occur in the first stage. MM. Eilliet and Barthez 
conclude that meningitis without complication of tuberculous disease of 
the cerebral substance, never begins with convulsions. In one of the 
cases that came under our charge, a severe and prolonged convulsive 
seizure did occur, however, on the very first &&y of the attack of the dis- 
ease. The subject of the case was a boy between four and five years old. 
The death took place on the eighteenth day, and the autopsy showed no 
tubercular disease of the cerebral substance. It is proper to state, how- 
ever, that the child had eaten on the morning of the day that he was 
attacked, a most unwholesome meal, and it is very possible, as we in fact 
supposed at the time, that the convulsions were caused by the presence 
in the stomach of undigested food. When they do occur in tubercular 
meningitis, they may be limited to the extremities, upper lip, eyeballs, 
or the}^ may be general. Sometimes the child dies in a convulsion. They 
are generally much less important as a symptom, according to M. Yalleix, 
than in simple acute meningitis. 

The tongue remains moist ; the appetite is not entirely lost ; thirst is 
moderate ; the constipation continues, unless removed by treatment ; the 
abdomen becomes retracted, so that its walls approach closely to the 
spinal column, and allow us to feel the pulsations of the aorta without 
using more than very slight pressure. The latter sj'mptom comes on 
gradually, and is generally well marked by the sixth day or a little later. 
MM. Rilliet and Barthez regard it as a very important sign, and state 
that they have observed it almost exclusive^ in cerebral affections. They 
think it depends not upon contraction of the abdominal muscles, but upon 
retraction of the intestines. We can corroborate by our own experience, 
the evidence of the above authorities as to the value of this symptom. 
It has been very marked in the cases that we have seen. 

The state of the circulation is of the utmost importance in forming the 
diagnosis. So true indeed is this, that Dr. Wlrytt, of Edinburgh, whose 
description of acute hydrocephalus, published in H68, has been most 
highly commended by all recent writers as a singular instance of accurate 
observation, makes three stages of the disease, each of which is charac- 
terized by the state of the pulse. In the early- part of the attack the pulse 
is accelerated, rising to 110, 120, or, according to Wlrytt, in a few cases 
to 130 or even 140. At the same time it is neither full nor tense, as a 
general rule, but rather soft and compressible. This condition of the 
pulse changes, as we shall find, in the middle period of the disease, and 



SYMPTOMS OF THE SECOND STAGE. 447 

again shortly before the fatal termination. The heat of the skin is usually 
moderate and sometimes quite natural, at this time, as might be supposed 
from the state of the circulation. 

Second stage.— This stage begins about the time the more marked ner- 
vous symptoms show themselves. The headache generally subsides or 
ceases at the beginning of this period and gives place to delirium. This 
occurs usually somewhere between the sixth and twelfth days. The de- 
lirium which occurs has been generally supposed to be alwa} T s mild and 
calm. MM. Rilliet and Barthez state, however, that in one-third of their 
cases it was intense, and accompanied with cries, agitation, and frequent 
changes of position. In most of the cases, however, it is mild, and is 
manifested in older children by their muttering unintelligible words, by 
inattention to what is going on around them, by an expression of wildness 
and astonishment, and by their giving hesitating answers to questions. 
In children under two years of age there is no proper delirium. There 
is, however, an analagous condition, which is characterized b} r disorder 
of the two faculties of attention and perception. The delirium seldom 
lasts more than two or three clays, and generally alternates with somno- 
lence, so that the child is either dozing and sleeping, talking in its sleep, 
or frequently waking with loud cries, and restlessness. The general sen- 
sibility, which ma} r have been exaggerated in the early period of the dis- 
ease, is diminished in the early part of the second stage, or about the 
seventh day, and completely abolished towards the end. The face in the 
second stage is almost always pale, or pale and flushed alternately. 
During this stage, and especially during the latter part of it, it is very 
common to see sudden alterations in the color of the face. Sometimes 
without smy apparent cause, but more frequently from disturbances of any 
kind, as from pain or from external influences acting upon the child, such 
as moving it, or the administration of food or medicine, the face becomes 
suffused of a more or less deep pinkish or scarlet tint, the color begin- 
ning faintly at first and gradually deepening and expanding until it covers 
the whole face and forehead, and then as gradually fading away. It is 
during this stage also that another symptom, which we have often noticed, 
and to which M. Trousseau has called attention, may usually be observed. 
M. Trousseau refers to it as a red line or spot remaining upon the skin of 
the forehead or abdomen when the finger has been drawn across it, and 
has given to it the name of "tache meningitique," or "tache cerebrate." 
We had often remarked, before knowing that M. Trousseau had drawn 
attention to this phenomenon, that the slightest pressure with the finger 
on an}^ part of the face or forehead, caused the appearance at the point 
of pressure, of a spot of a peculiar pink or rose color, which, like the flush 
above referred to, began faintly, became more or less deep in tint, re- 
mained a few moments, and then as gradually faded slwslj. This is no 
doubt one of the diagnostic symptoms of the disease. We do not recol- 
lect to have seen it in any other disease, except once in a severe case of 
typhus fever in an adult, in whom it was exceedingly marked. In this dis- 
ease we believe it may always or nearly always be detected. Occasionally 
contractions pass over the features, giving rise to grimaces, after which 



448 TUBERCULAR MENINGITIS. 

the countenance resumes its expression of indifference and stupor. The 
eyelids are generally only partially closed, and between them the globes 
of the e} T es can be seen to oscillate and move in various directions, as 
though by some automatic force. 

As the case progresses, the nervous symptoms become more and more 
marked; somnolence gradually deepens into coma; the delirium becomes 
less and less frequent; and the child no longer observes what is going on, 
nor answers questions. As the somnolence and coma increase, various 
lesions of motility make their appearance, consisting, in order of fre- 
quency, of paralysis, which is generally partial; contraction with rigidity 
of the limbs ; stiffness of the muscles of the back of the neck, causing 
retraction of the head ; stiffness of the trunk ; spasmodic closure of the 
jaws ; carphologia ; subsultus tendinum, and convulsions. The paralysis 
is almost alwa} T s partial and of very limited extent, affecting, for instance, 
the jaw, the orbicularis muscles of the eyelids, the levator of the upper 
ej 7 elid, the tongue, or one side of the face. It is very rare to see one of 
the limbs paralyzed. Contraction with rigidity of the muscles is an im- 
portant symptom, but is not alwa} T s present. When it exists it generally 
appears at an advanced period of the attack, commonly between the 
seventh and thirteenth days, and is usually partial. It may affect either 
the extremities, back of the neck, trunk, or inferior maxilla. It is seldom 
permanent, but after lasting one or two days, disappears, to reappear at 
a later period. The carphologia, subsultus, and chewing motion of the 
under jaw generally occur only a few days before death, and last but a 
few days. 

The decubitus, in the early part of the second stage, is generally lateral, 
with the thighs flexed upon the pelvis, the legs upon the thighs, the arms 
applied against the thorax, the elbows bent, and the hands placed in front, 
the decubitus, called by the French " en chien de fusil " or gun-hammer. 
At this time the child will still occasionally move its position with facility, 
showing that strength is not by any means entirely lost. At a still later 
period the decubitus is dorsal. In the latter part of the first and early 
part of the second stage, the pulse, which we have ascertained to be 
accelerated at the invasion, falls to the natural standard, or becomes 
slow, and at the same time irregular. From 110 or 120, as it was, it now 
sinks to 90, 80, 60, or, as happened in one instance to M. Guersant, to 48 
in the minute. Coincident^ with this change it almost alwa3 T s becomes 
irregular. The irregularity affects both its force and frequency, so that a 
strong pulsation may be followed by a feeble one, or the rhythm may be 
regularly or irregularly intermittent. The irregularity varies greatly at 
different periods of the day, or within short spaces of time, so that the 
pulse is found to be very slow at one moment and much more frequent 
the next. On this account it is necessary to examine it on different 
occasions. Slowness and irregularity of the circulation are important as 
a means of diagnosis, since it has very rarely been met with as a perma- 
nent condition, except in the tuberculo-inflammatory affections of the 
brain and its appendages. Towards the termination of the disease, gene- 
rally speaking two or three days before death, the pulse rises again in 



DIAGNOSIS. 449 

frequency, so that it counts at first 112 or 120, and gradually increases 
to 140, 160, or even 200 the day before, or that on which death takes 
place. Simultaneously with this change it also becomes extremely feeble 
and small, and often ceases to be perceptible at the wrist on the last da} r . 
The heat of skin generally increases with the acceleration of the pulse. 
This is not invariable, however, since in some cases the temperature 
remains but moderately elevated, about 101° or 102° until death; and in 
others an algid condition precedes death, in which the temperature falls 
as low as T9.I°. (Beynolds's Si/st. of Medicine, vol. ii, p. 3T9, art. Tuberc. 
Meningitis.) During the last few clays the surface is often covered with 
an abundant perspiration ; the tongue becomes dry ; the teeth and gums 
are fuliginous ; the exhaustion increases ; the respiration becomes stertor- 
ous, unequal, difficult, and anxious, and at the very last attended with 
great dyspnoea ; and the urine and stools are discharged involuntarily. 
Death finally occurs in this condition, or is hastened b}^ an attack of 
convulsions. In some cases it is most lingering. In one instance we 
expected the death of a young child in this disease every day for eight in 
succession. 

The duration of tubercular meningitis is exceedingly variable in dif- 
ferent cases. As a general rule it lasts between eleven and twenty days, 
though it may continue a considerably longer time. Rilliet and Barthez 
have never known death to occur before the seventh day. 

Diagnosis. — The diseases with which tuberculosis of the meninges is 
most likely to be confounded are simple meningitis and typhoid fever. It 
might also be confounded, though this is much less probable, with the 
cerebral s^miptoms which complicate the exanthemata and some local dis- 
eases, especially pneumonia, and to which symptoms, as a group, M. Bar- 
rier has applied the term pseudo-meningitis. 

The diagnosis between tubercular and simple meningitis will be best 
understood from the following synoptical table, extracted from the last 
edition of the work of MM. Rilliet and Barthez. 

SIMPLE ACUTE MENINGITIS. REGULAR TUBERCULAR MENINGITIS. 

I. The subjects of acute simple menin- I. Subjects of tubercular meningitis 
gitis are usually .robust and well devel- delicate, puny, exhibiting often preco- 
oped, and present no trace of either inter- cious intelligence and sensibility. Have 
nal or external tubercular disease. Born sometimesbad, in infancy, enlarged glands 
of healthy parents. or chronic cutaneous eruptions ; the pa- 
rents, or brothers and sisters, often present 
the signs of tubercular disease. 

II. The disease may prevail epidemi- II. Disease always sporadic, 
cally. 

III. Condition prior to invasion. — The III. Condition jjrior to invasion. — For 
disease begins in the midst of the most some months or weeks the patients grow 
blooming health, or, if secondary, it occurs languid, lose their strength, become pale, 
in the course of, or during the convales- emaciate ; their temper changes, the}' are 
cence from, some acute non-tubercular dull, they lose appetite, the digestion is 
disease, or it follows an external cause. deranged, &c. Absence of prodromic 

symptoms is rare. 

29 



450 



TUBERCULAR MENINGITIS. 



SIMPLE ACUTE MENINGITIS. 

IV. Mode of Invasion. — Violent con- 
vulsions attended with intense febrile 
movement, and with very hurried respi- 
ration in young infants ; or very acute 
frontal headache, accompanied by fever, 
bilious vomiting, and towards the end of 
the first, or in the course of the second 
day, at the latest, excessive restlessness, 
preceded or not by somnolence ; most vio- 
lent delirium ; formidable ataxia. 



V. Symptoms. — Very intense headache, 
obstinate vomiting, moderate constipation, 
violent fever, high delirium. 



VI. From the beginning, the aspect of 
a grave disease of ataxic form. 

VII. Course rapid, aggravation pro- 
gressive and continuous ; convulsion after 
convulsion, or else violent delirium, ex- 
treme agitation, violent fever, &c. 

Duration. — Disease of short duration, 
ending sometimes in 24 or 36 hours, but 
lasting generally from three to six days, 
and seldom more. 



REGULAR TUBERCULAR MENINGITIS. 

IV. Mode of invasion. — Never with con- 
vulsions at the onset ; the change from the 
prodromic to the acute stage sometimes 
imperceptible. It takes place by a pro- 
gressive increase of the symptoms before 
mentioned, and by the setting in of head- 
ache ; in other cases, the acute state is 
better marked by headache, vomiting, and 
constipation ; generally, the intelligence 
remains clear ; no ataxia. In the rare 
cases in which there is ataxia at the onset 
of the acute symptoms, the prodromic 
stage, above described, has been observa- 
able, or the meningitis has occurred in 
the course of advanced phthisis. In cases 
in which no prodromes exist, the menin- 
gitis begins with vomiting, constipation, 
moderate headache, and slight febrile 
movement; ataxia, if it is to appear, oc- 
curs later, and a mistake is impossible. 

V. Symptoms. — Not very intense head- 
ache, vomiting less frequent, very obsti- 
nate constipation, very moderate fever, 
slowness and irregularity of the pulse, 
delirium usually mild. 

VI. Invasion insidious, with the aspect 
of a mild disease. 

VII. Course slow, preservation of the 
intelligence to an advanced period, fever 
slight, and some slowness and irregularity 
of the pulse, sighing, changing color of the 
face, eye dull or ecstatic, &c. 

Duration. — Always much longer in the 
regular form. 



TTe will remark in regard to this table, which is, in most respects, ad- 
mirable, that we have never met with more intense and persistent head- 
ache than we have in some cases of the disease under consideration. In 
some of our cases this has been a most prominent and striking sjmiptom. 

Before quitting the subject of the diagnosis of these two affections, it 
is desirable to state for the information of the reader, that some of the 
highest authorities acknowledge it to be sometimes nearly or quite im- 
possible to distinguish between them. This is the expressed opinion of 
MM. Guersant, Rufz, Barrier, and Valleix. 

From typhoid fever, tubercular meningitis is to be distinguished by the 
antecedent history of the patient, which often reveals the existence of a 
tubercular diathesis in the latter affection ; by the s} T mptoms of the inva- 
sion, which in meningitis consist of severe and persistent headache, fre- 
quent vomiting, and constipation, whilst in typhoid fever the headache is 
less severe and less persistent, the vomiting much less frequent, and the 



PROGNOSIS. 451 

constipation replaced b} y diarrhoea ; by the different characters of the feb- 
rile movement, which, in typhoid fever, is more marked, and attended 
with a frequent, full, and regular pulse, while in meningitis it is less 
marked and is accompanied after a few days by slowness and irregularity 
of the pulse ; lastly, in meningitis, the constipation is obstinate, the abdo- 
men retracted, and there are various important and characteristic lesions 
of motility, and the special senses ; in typhoid fever there is diarrhoea, 
the abdomen is distended and meteoric, there are characteristic rose- 
colored spots, whilst there are no considerable lesions either of motility, 
or of the special senses. 

In one of our cases we made this mistake. And yet, on looking back 
at the case, we could see that the very moderate heat of skin, the absence 
of diarrhoea and of epistaxis, and the imperfect development of the erup- 
tion, which consisted only of a few faint rose spots on the abdomen, ought 
to have led us to suspect that the fever was of the tuberculous, and not 
of the typhoid form. 

It is unnecessary to do more than allude to the possibility of confound- 
ing the disease with the exanthemata, or with local diseases accompanied 
by cerebral symptoms, and particularly with pneumonia in very young 
children. The resemblance of pneumonia of the apex of the lung in the 
earl}' stage, to tubercular meningitis, has been referred to in the article 
on pneumonia. The diagnosis must be made by careful consideration of 
the symptoms peculiar to each, and in the case of a local disease, bj r ac- 
curate physical examination of all the important organs of the body. 

Prognosis. — M. Barrier, in speaking of the prognosis of this affection, 
says : " The gravity of tubercular meningitis is not surpassed by that of 
any other disease. Thoracic and abdominal phthisis, though almost con- 
stantly fatal, pursue a slower course, and last a longer time. We may 
even allow as proved, that in a small number of cases, they are suscepti- 
ble of cure, or may remain stationary for months or years. Unfortu- 
nately it is not so in regard to tubercular meningitis. " MM. Rilliet and 
Barthez, in their second edition, do not express the same entire hopeless- 
ness as to recovery from the disease, that they did in their first. They say, 
amongst other conclusions (op. cit., t. iii, p. 510), that there are on record 
incontestable examples of the complete disappearance of the symptoms, 
but remark, that snch cures have occurred in the first stage, or in the first 
half of the second stage, after seven or eight days of sickness, rarely 
later, and after alternations of amelioration and aggravation. They state 
also that, in excessively rare instances, a return to health has been ob- 
tained even in the course of the third stage, after many weeks of illness. 
They are of opinion that the disease often returns and proves fatal in 
from one to five years and a half after the recovery. The cause of the 
relapse is to be found in the fact that the local lesion remains, and that 
the diathesis has not been eradicated. M. Valleix is of opinion that after 
having acquired the conviction that a case is really one of tuberculosis 
of the meninges, we should regard the patient as lost ; " for the excep- 
tion that I have mentioned (a case belonging to M. Rilliet, then unpub- 
lished), even did no doubt as to the exactness of the diagnosis remain, 



452 TUBERCULAR MENINGITIS. 

ought not, standing by itself, to impart to us any real security." M. 
Guersant {Diet, de Med. t. xix, p. 403), seems to think it possible that 
the disease may sometimes terminate favorably in the very early stage, but 
adds that u such cases are always more or less doubtful, and seem to us to 
belong rather, for the most part, to simple meningitis." During the second 
period (that of slowness and irregularity of the pulse), he has scarcely 
seen one child in a hundred survive, and even then they perished at a 
later period of the disease, or of phthisis pulmonalis. Of those arrived 
at the third stage (marked by renewed frequency of the pulse, coma, and 
lesions of motility and sensibility), he has never seen any recovery, even 
momentarily. Dr. George B. Wood {Prac. of Med., vol. ii, p. 365), states 
that he has " never seen a well-marked case of tuberculous meningitis 
end favorably." 

We shall quote but one more authority as to the prognosis of the dis- 
ease. Dr. Robert Whytt {Works of Robert Whytt, published by his son, 
quarto, Edinburgh, 1768, p. 745), says : "I freely own, that I have never 
been so lucky as to cure one patient who had those s}'mptoms which with 
certainty denote this disease ; and I suspect that those who imagine they 
have been more successful have mistaken another distemper for this." 
Our own experience coincides with the mass of evidence given above as 
to the almost hopeless fatality of the disease. The thirty-one cases that 
we have seen all proved fatal. A case, however, came under our obser- 
vation, in 1850, which might, perhaps, be classed as a recovery from 
tuberculosis of the meninges, though not from tubercular meningitis, 
since there were no well-marked signs of inflammation of the membranes 
of the brain, though there was every reason to suppose that the sjunptoms 
depended on the deposit of tubercles in those membranes. The case was 
as follows : A girl between four and five years old, whose mother was then 
laboring under tubercular disease of the summit of one lung (which has 
since proved fatal), and who had lost several brothers and sisters with 
consumption, had had nearly constant cough during the winter of 1849-50. 
During the months of April, May, and June, of 1850, she had exhibited 
all the signs of induration over the upper two or three inches of the right 
lung, before and behind, — marked dulness on percussion and bronchial 
respiration, but no rale. For these sjunptoms she had been treated with 
cod-liver oil, iodide of iron, opium for the cough, and good diet. From 
the middle of June she complained frequently of headache, had occasional 
vomiting without any gastric derangement, and was much disposed to be 
constipated. She had no appetite, grew thin, and was very languid, listless, 
and weak. On the 27th of June the mother thought she observed some 
squinting. On the 29th we found that the child had lost all power over 
the right muscles of the right e} T e, so that w r hen she looked towards the 
right hand, sbe squinted dreadfully. She was dull and heavy, and 
vomited two or three times a day. The pulse was 62 to 75 or 80; there 
was a slight hitch in its beat, but no decided intermittence. The child 
said that she sometimes saw two things instead of one. From this time 
until July 7th, she continued in much the same state. On the 1st July, 
finding that the eyes were quite yellow, and that the child was consti- 



PROGNOSIS. 453 

pated, we ordered half a grain of calomel morning and evening. After 
three doses she was purged. This relieved her a good deal, there being 
less headache, more appetite, and an improvement in color afterwards. 
But still there was eveiy day some vomiting, complaints of headache, 
and more or less listlessness and heaviness in the morning, while in the 
afternoon she would brighten up and seem better. The intelligence con- 
tinued perfect ; the temper was rather irritable, but not very much so. 

The treatment after the 29th of June was calomel, given as above stated, 
from time to time, to keep the bowels soluble ; cod-liver oil, a teaspoonful 
twice or three times a day, as the child would take it ; mustard foot-baths 
every day or two ; and meat, bread, and ice cream for diet. On the 5th 
July we ordered half a grain of iodide of potassium, three times a day, 
in addition to the oil. 

On the 11th July, she was taken, by our direction, to the seaside, where 
the use of the oil and of the iodide of potassium was to be continued. 

On the 7th of August she was brought back from the seaside, and we 
saw her on the 8th. We were astonished to see how well she looked. 
The strabismus had entirety disappeared. We were told that it had 
begun to diminish two weeks after her arrival at the sea, and had then 
gradually disappeared. She had grown somewhat, though not very much, 
fatter. Her whole appearance was very much improved. The coloration 
of the bocVy, the expression of the face, were both much better ; she was 
much stronger, running about, in fact, all day ; she ate well, and with the 
exception of a little cough, and a rather delicate frame, looked very well. 
Except one da}', she was well all the time at the seashore. On that day 
she was feverish, had much headache and vomiting, and laid abed. The 
cod-liver oil and iodide of potasium were ordered to be continued. 

The child remained pretty well throughout the winter of 1850-51. 
There was no return of either the strabismus or the vomiting. She was 
thin, pale, and delicate-looking, coughed occasionally, and the solidifica- 
tion of the summit of the lung continued, but she was not confined to the 
house. Late in the winter she went south with her mother, and there, 
after having become quite stout and healthy during their travels, died of 
dysenteiy in April or May. The mother died in 1852 of phthisis, with 
large cavities in both lungs. Another case in which the early symptoms 
of the disease were well marked, and in which recovery took place, will 
be detailed in the remarks on prophylactic treatment. 

We have seen but two other cases which gave us the least reason for 
hope, after we had once supposed the children attacked with the disease. 
One occurred in a boy eight years old, who had been suffering for two 
weeks before we saw him with violent frontal headache, frequent vomit- 
ing, constipation, slight fever, and somnolence. We fully expected that 
this would prove to be an attack of tubercular meningitis. A large dose 
of calomel followed by castor oil, and free leeching to the temples, relieved 
him in two daj T s perfectly, and he has remained well ever since, though 
this was nearly twenty years ago. 

The second occurred in a boy also eight years of age, whose father had 
died a few years before of phthisis, the 3 r ounger brother died of tuberculous 



454 TUBERCULAR MENINGITIS. 

meningitis, and the sister of hooping-cough, with the lungs filled with 
miliary tubercles, as ascertained by a post-mortem examination. The 
child, after having had fair health previously, was seized towards the end 
of March, 1865, with frontal headache, very slight fever, occasional 
vomiting, constipation, hesitating pulse, languor, willingness to lie abed, 
and a tendency to somnolence. He was treated with rest, milk and beef- 
tea in alternate doses, and mustard foot-baths morning and evening ; the 
bowels were kept moderately open, and he took tincture of the chloride 
of iron in combination with dilute acetic acid and solution of the acetate 
of ammonia every three hours. Under this treatment he improved, and in 
ten days had quite recovered. The diagnosis at the time was tubercular 
meningitis in the early stage. His mother removed from this city to 
Washington, where he died on the 30th of June of the same year, after 
an illness of twenty-one da} T s, of what was called water on the brain. 

In another case to which one of us was called in consultation, a boy, 
whose mother had died a few years before of diabetes mellitus, and whose 
father's family was tuberculous, presented a series of s} T mptoms which we 
could explain only as the result of slow thickening of the membranes at 
the base of the brain, in all probability the result of a tubercular deposit. 
This child had, for several weeks, violent frontal headache, constipation, 
loss of flesh, lassitude, a peculiar one-sided or lateral gait in walking, 
strabismus, and great impairment of vision, so that he could see a small 
object only b} r bringing it almost in contact with the face. There was 
scarcely any disturbance of the circulation, and only slight febrile heat 
at night. He was treated at first with rest, nutritious food, minute doses 
of bichloride of mercmy in combination with iodide of potassium, three 
times a daj^, and then when he began to improve, with tincture of the 
chloride of iron and cod-liver oil for a long period. He finally recovered 
his health, grew stout and strong, but has remained ever since so blind 
that he reads with great difficulty, but manages to pick his way through 
a room or the street, with onry occasional stumbling. The illness occurred 
several 3 T ears ago, and he is still living in good general health at this 
time (1869). 

Are we then to abandon all hope of deriving any good from medical 
means in the disease under consideration ? To this most serious question 
we ought clearly to respond in the negative. The grounds for entertain- 
ing hope are first, the evidence of M. Guersant that he has seen cases 
which appeared to be tubercular meningitis recover in the first stage. 
Let it be supposed, even, that they were cases of simple inflammation. 
But they were unclistinguishable from the tubercular disease by one of 
the most celebrated of modern plrysicians. Surety, therefore, it 'may 
happen to men of inferior skill to meet with the same difficult}^ or if we 
may so speak, to make the same mistake, if a mistake was made. It is 
said by M. Yalleix, that M. Rufz, after determining at the autopsy, that 
a case which he had witnessed was one of simple meningitis, asserted that 
it would have been impossible to distinguish it from the tubercular dis- 
ease during life. Again, M. Rilliet has, according to M. Yalleix, seen 
one case of recovery from what he believed to be the tubercular affection. 



TREATMENT. 455 

and MM. Rilliet and Barthez, in their second edition, as above quoted, 
assert its occasional curability. We know of the occurrence of a case in 
this city, under the charge of one of our friends, than whom we believe 
no one can be more competent to make a correct diagnosis, in which, 
after the child had presented in regular order all the early symptoms of 
the disease, and had arrived at the last and most hopeless stage, perfect 
recovery, to his utter amazement, gradually took place. This child, when 
our friend last heard of it, three months afterwards, was in all respects 
strong and hearty. No doubt the probabilities are that the case was one 
of simple meningitis, but who could have known this at the time ; and 
should it not deter us from abandoning all hope, and, as a consequence, 
all active treatment, when we seem to have under our hands a case of this 
dreadful malady? Our own cases, given above, also goto prove that the 
disease is sometimes curable in its early stages. 

It is important, in tubercular meningitis, to avoid making a positive 
prognosis as to the period at which death will occur, notwithstanding that 
the patient may present every mark of an immediately fatal termination. 
"We have already adverted slightly to this subject. On one occasion we 
expected the death of a patient with this malady for three days in suc- 
cession, and on another, we visited a child for a week, during every day 
of which it seemed as though existence could not endure until the next. 
It had during this time profound coma,subsultus tendinum, and enlarged 
pupils ; the eyelids were half open, the eyes constantly oscillating, or else 
rigidly distorted, and both corneas dimmed and slightly eroded, from 
constant exposure to air and light. Convulsions occurred from time to 
time, the pulse was variable, and at times exceedingly frequent, and indeed 
every thing threatened a speedy termination. MM. Rilliet and Barthez 
say, " Often have we inscribed upon our notes death imminent, and been 
astonished the next day to find still alive, children to whom we had 
allowed scarcely two hours of life." 

The symptoms which most positively indicate the near approach of 
death are, livid color of the face, sweats occurring about the face, glassy 
expression of the eye, dry and incrusted nostrils, and especially a very 
rapid pulse, and the various nervous sjmiptoms mentioned, as carphologia, 
subsultus tendinum, and general convulsions. 

Treatment. — In the last edition of this work we took the ground that 
it was proper in the early stage of the disease to employ bloodletting. 
Further experience and knowledge compel us to retract this opinion. 
We believe now, that abstraction of blood should not be resorted to 
unless when the diagnosis between this disease and simple meningitis is 
very uncertain. Where there are no marked signs of active inflamma- 
tion, where, from the family history, from the absence of marked fever, 
and the peculiar state of the pulse, we have every reason to believe that 
the low-typed inflammation present is the result of the presence of tuber- 
cle, we deem it safest to avoid all lowering measures. The case is so 
critical, so almost hopeless from its very nature, that we prefer a treat- 
ment based on the theory of promoting a retrogression of the tuberculous 
deposit. The only measures which, in an experience of twenty-seven 



456 TUBERCULAR MENINGITIS. 

years, one of us has found to delay and, in the cases referred to in the 
article od prognosis, to cure the disease in part, have been the following: 
quiet of body and mind, obtained by means of rest in or on the bed, in 
a pleasant room, with attendants who know how to soothe and still the 
child. We always insist upon a nutritious diet : and one consisting mainly 
of milk or cream, or the two mixed, with beef tea, bread and butter, if the 
patient will take it, or milk-toast, in moderate quantities every three or 
four hours, a soft-boiled egg, or the yelk of a hard-boiled egg, once or 
twice a day, is what we usually endeavor to get the patient to take. A 
mustard foot-bath two or three times a day, is always safe, and we think 
useful and tranquillizing. The bowels should be moved gently once a 
daj T , or every two cla} T s, by means of an enema or some simple laxative, 
as simple syrup of rhubarb. Active purgation we have found of no use. 
As remedies, we prefer the following: 

R.— Tr. Ferri Chlorid., . . . . . . f£j. 

Acid. Acet., Dil., f £j. 

Liq. Amnion. Acetat , ..... fgij. 

Syrup. Simp., f^j. 

Aquae, f^ijss. — M. 

A teaspoonful at five years of age, every three or four hours. 

In connection with this, we give half a teaspoonful of cod-liver oil in 
emulsion three times a da}^. Calomel we have abandoned of late years 
entirely, as it has utterly failed in our hands to do any good. 

Iodine has been very much employed as a remedy in this disease, both 
in the forms of Lugol's solution and iodide of potassium. Perhaps the 
strongest argument which exists in its favor is the benefit which often 
follows its employment in other scrofulous and tuberculous diseases; 
though there are several cases in which it is asserted to have been suc- 
cessfully used in tubercular meningitis. Iodine itself is comparatively 
little used. M. Rilliet (op. cit., t. iii, p. 308, 1847) states that it has en- 
tirety failed in his hands in the tubercular form of the disease ; the only 
influence wiiich it seemed to exert was to cause the immediate suspension 
of the coma. This was its effect also in a case in which we employed it, 
that of a girl seven years old, to whom we gave two drops of Lugol's so- 
lution three times a day, from the thirteenth to the twentieth clay, when 
she died. The day before her death she seemed to improve somewhat, 
and w T e were in hopes that it had been of some service. The ameliora- 
tion did not continue, however, and we are now disposed to believe that 
the change was one of those which often take place naturally in the dis- 
ease. 

Iodide of Potassium was recommended more than twenty years ago by 
Koeser (Huf eland's Journal, April, 1840), as a remecly of special power 
in this disease. It has since then been very widely employed, and there 
are quite a number of cases in which it is asserted that its administration 
was followed by successful results. 

Dr. West (op. cit., 4th Amer. ed., p. 97) thinks that he has seen good 
from its employment, " and that in one instance of what seemed to be ad- 



TREATMENT — IODIDE OE POTASSIUM. 457 

vanced tubercular hydrocephalus, under the care of my friend and former 
colleague. Dr. Jenner, recovery took place under its employment." 

Niemeyer (op. cit., vol. ii, p. 218) speaks as follows of its use: "On the 
strength of two successful cases, opposed, it is true, by a large number of 
unsuccessful ones, I recommend large doses of iodide of potassium, con- 
tinued for a long time." 

Dr. J. Lewis Smith (op. cit., p. 145) also recommends its use through- 
out the entire disease, beginning as early as possible in the premonitory 
period. 

Successful cases of its administration are also reported by Drs. Bour- 
rouse de L afore, Coldstream (Edin. Med. Jour., Dec. 1859) ; and Carson- 
fifed. Times and Gaz., March 5th, 1857). 

We have ourselves frequently administered it, either alone or in com- 
bination with small doses of bichloride of mercury, but have not yet been 
fortunate enough to arrest the progress of any case when once the second 
stage has been fully developed. In a few cases, however, the use of the 
following combination: 

R. — Potass. Iodidi, gj. 

Hydrarg. Chloridi Corrosivi, .... gr. j. 

Syr. Simp., fgj. 

Aquse, fjhj- 

Ft. sol. Dose, a teaspoonful three times a day at five years of age. 

has seemed to delaj^ the march of the disease, in one some weeks, and in 
another, the one already mentioned, it seemed to have a positive effect 
in promoting the absorption of the exudation upon the membranes at 
the base of the brain. It is improbable, also, that in all of the reported 
cases, errors of diagnosis were made, and simple meningitis taken for the 
tubercular form ; so that there is no remedy from which so much benefit 
may be hoped for in this almost hopeless disease, as iodide of potassium 
in full doses, and it should therefore be faithfully tried whenever oppor- 
tunity offers. We have been in the habit of giving it in doses of one or 
two grains every three or four hours, to children two years of age. It 
has, however, been given to the extent of a drachm in the course of a 
single day to children of that age. It ought to be begun with early in 
the case, and continued in connection with counter-irritation and cold to 
the head. We must remark, however, that it sometimes irritates the 
bowels too much, causing diarrhoea; and here the dose ought to be 
greatly reduced, or the remedy withdrawn. 

The treatment which has just been described, is that which we have 
been led by our convictions as to the nature of the disease, and by our per- 
sonal experience of different plans, to adopt as the most reasonable and 
the best. It is proper to state, however, that we have never seen it, nor 
any other method, of any avail after the disease has passed into the latter 
part of the second stage — when coma, dilatation of the pupils, marked 
strabismus, paralytic or convulsive phenomena, show the presence of in- 
flammatory exudation under the membranes, and of serous effusion into 
the lateral ventricles, or the peculiar lesions of the substance of the brain, 



458 TUBERCULAR MENINGITIS. 

which exist at that period of the malady. It is also proper to add that 
other means have been recommended by high authorities, and to these 
we shall now devote some remarks. 

Counter-irritation in different forms has been emploj'ed, and apparently 
with success, though it has failed in our hands. Blisters to the nucha, 
behind the ears, or over the whole scalp, have been used. At one time, 
in this cit3 T , it was a common practice' to cover the scalp with a blister, 
but it was found to fail so constantly, and was so painful a sight to the 
relations of the child, that it has been very much abandoned. Surely, if 
it had succeeded in any considerable proportion of the cases, it would 
have been received as a boon, however revolting to the sight. We have, 
ourselves, in past 3 T ears, blistered the nucha, the back of the ears, and 
the temples in a number of cases, but have always failed to obtain any 
evident good from them. Within a few years it has been claimed that 
pustulating the whole sinciput with croton oil has been of great service. 
The last case of tuberculous meningitis we saw, occurred in an adult, and 
here we had nearly the whole of the crown of the head shaved and pustu- 
lated with the oil, but it was of no use whatever. 

Cotd applications to the head have been very much used. We have 
emplo}'ed them ourselves, and still use them whenever the head is hot, or 
when their use relieves the headache or soothes the patient, but we con- 
fess that they have not seemed to us of much use except as palliatives. 
They r ma} T consist of cloths wet with cold water, of affusions with cold 
water, or as has been proposed by M. Guersant, of irrigation as em- 
ployed in surgery. M. Guersant prefers this mode of applying cold to 
anj^ other, believing it to be the most convenient and comfortable to 
the child, and from its continuous action, the most efficacious. To make 
use of it the hair is to be shaved or closely cut, and the child placed upon 
a mattress without a pillow, and with its head near the edge of the bed. 
The head is then covered with compresses of soft rag, or better still, of 
patent lint, while under it is placed a piece of oiled silk or india-rubber 
cloth, so arranged as to keep the thorax from being wet, and doubled 
into a gutter above to convey the water off into a vessel placed on the 
floor. A bucket or basin filled with fresh, cool water, is placed near the 
head of the bed, and from this a syphon made of lint or lamp-wick is so 
arranged as to conve}^ a stream of water upon the compresses covering 
the head. If the heat of the whole bod}?- falls so much as to threaten col- 
lapse after the irrigation has been continued for some time, the stream 
of water should be stopped, and compresses, merely wet with water not 
quite so cool, kept on the head. The latter precaution is necessaiy in 
order to prevent injurious reaction from the sudden and total removal of 
so powerful a sedative as irrigation proves to be. 

Some practitioners prefer the use of ice in a bladder. This seems, how- 
ever, too severe a remedj^ to be long continued, and we should therefore 
rather use onty cloths wet with iced-water, or irrigation. Dr. Abercrombie 
is of opinion that the application of cold is hy far the most powerful 
local remedy that we have. M. Gendrin recommends cool or cold affu- 
sions over the whole surface, the temperature to be proportioned to the 



TREATMENT — USE OF CALOMEL. 459 

heat of the skin. When there is but little heat of head, only a slight 
febrile movement, and the headache is not relieved by cold application, 
GKiersant recommends the substitution of warm poultices to the scalp, in 
the place of irrigation or cold applications. 

TVe have already stated that calomel has not succeeded in our hands, 
so that we have abandoned its use. We deem it right, however, to lay 
before the reader the opinions of others upon this point. Thus, it is 
highly recommended by many of the English writers on acute hydro- 
cephalus, and is asserted to have effected cures when it has been pushed 
to such an extent as to produce salivation. But little dependence, how- 
ever, can be placed on these assertions, as in all probability the reported 
recoveries occurred in cases of simple meningitis. The French writers 
speak of having used it in very large quantities without any success. It 
was given to many of the patients of MM. Rilliet and Barthez, in the 
quanthy of from six to ten, increased to twenty grains, in twenty : four 
hours, in connection with frictions with mercurial ointment, of which two 
drachms and a half were used at first, and the quantity afterwards 
doubled and trebled. They state that salivation did not occur in any of 
the cases, though fetor of the breath and inflammation of the gums were 
of frequent occurrence. Calomel may be given, as has been remarked, 
in purgative doses, at the beginning, and for the purpose of procuring its 
specific effects. With the latter view the dose may be from a quarter of 
a grain to a grain, every hour or two hours. Mercurial inunction, in con- 
junction with the internal administration of the remedy, has been highly 
recommended by several writers as an efficient means of procuring the 
full effect of the drug upon the constitution. About a drachm of the oint- 
ment is to be rubbed into the insides of the arms and thighs morning and 
evening, and the quantity gradually increased if no effect is produced. 
For our part, we will merely state that we have never known calomel given 
in large quantities, in order to procure salivation, of the least benefit in 
the disease. On the contraiy, we cannot but think that the violent irri- 
tation of the digestive mucous membrane which it has determined, when- 
ever we have used it largely, and the inflamed, irritated condition of the 
mouth which it caused in one case, must have been a serious aggravation 
of the state of disease under which the constitution was laboring. Mer- 
cury is well known to be an injurious and dangerous remedy in the tuber- 
cular diseases of adults, having for its effect to increase the dyscrasia of 
the constitution, which already exists, and thereby to hasten the progress 
of the malady. Why it should have a different effect in children is diffi- 
cult to understand. It may be said, to be sure, that in the disease we are 
considering, it is given to overcome the inflammatory element of the 
malady, which, for the time, constitutes the danger of the case, and also 
to allow the patient the chance of its beneficial operation should the dis- 
ease happen to be one of simple meningitis. In support of the views just 
expressed, we will quote the opinion of Dr. John Abercrombie (Diseases 
of the Brain and Spinal Cord, Philad. ed., 1831, p. 173-6) : " Mercury has 
been strongly recommended in that class of cases which terminates b} T 
hydrocephalus, but its reputation seems to stand upon very doubtful 



460 TUBERCULAR MENINGITIS. 

grounds. In many cases, especially during the first or more active stage, 
the indiscriminate employment of mercury must be injurious. ... In 
the preceding observations, I shall perhaps be considered as having at- 
tached too little importance to mercury in the treatment of this class of 
diseases, particularly in the treatment of hydrocephalus ; but in doing so, 
I have stated simply what is the result of an extensive observation, . . . 
and- I confess, the result of my observations is, that when mercury is 
useful in affections of the brain, it is chiefly as a purgative." 

It has been recommended, within a few 3-ears, by Sir B. Brodie, to em- 
ploy mercurial inunction as especially applicable in using mercury for 
children. He advises that a drachm or more of the ointment be spread 
upon one end of a flannel roller, which is to be applied, not very tightly, 
around the knee; repeating the application daily. " The motions of the 
child produce the necessary friction ; and the cuticle being thin, the mer- 
cury, easily enters the system." The editors of the journal in which this 
communication is made (Braitli. Retrosp. of Med., vol. iv, 1846, p. 14*7, 
from Quart. Med. Bev., July, 1846, p. 169), state that thej' tried this plan 
in a case of acute hydrocephalus, in which some of the most urgent and 
fatal S3 T mptoms were present, " such as very dilated pupils, constant con- 
vulsions, hemiplegia, and more or less stertorous breathing; in short, so 
violent were the symptoms, that we considered the case perfectly hope- 
less ; but on reflecting on Sir Benjamin's method, we ordered strong mer- 
curial ointment to be smeared on each leg, every twelve hours, and 
covered with a stocking made to tie tightly above the knees. The symp- 
toms soon began to abate, and by following this up with small doses of 
iodide of potass., frequently repeated (gr. i, every three or four hours), 
the head symptoms vanished. 

"In a second case, the same set of symptoms were approaching, but 
were stopped by the same mode of treatment." 

When the convulsive symptoms are violent and distressing, the}^ may 
often be moderated by the use of a warm bath, which must be carefully 
given, and by the administration of some, of the antispasmodics. We 
prefer for this purpose the fluid extract of valerian, of which from ten to 
twenty drops may be exhibited every two or three hours to young chil- 
dren, and a larger dose to those who are older. Bromide of potassium 
has also been recommended on account of its peculiar sedative action, 
and M. Bazin (Gaz. des Hopitaux, 1865) narrates a case in which large 
doses of this remedy were successful in checking the progress of tuber- 
cular meningitis, in a lad who presented at the same time the symptoms 
of pulmonary tuberculosis. 

As a general rule, narcotics of all kinds are to be avoided, from their 
effect of increasing the constipation, and exciting more or less the cere- 
bral circulation. When, however, neither antiphlogistics, evacuants, nor 
cold or warm applications relieve the sufferings of the child, it would be 
proper to employ small laudanum poultices or opium plasters upon the 
forehead or temples, or we may use morphia by the endermic method. 

The treatment described in the preceding pages, is that which is proper 
for cases of the disease occurring in subjects previously in good health, 



PROPHYLACTIC TREATMENT. 461 

or evincing but few signs of the tubercular cachexia. When, on the con- 
trary, it occurs in children with extensive tubercular affections of other 
organs, by which they are already weakened and exhausted, the treatment 
must of course be modified to meet the circumstances of the case. It 
ought to consist chiefly of cold applications, and of an early use of cod- 
liver oil, of iodine, or of the iodide of iron. We should recollect that ex- 
perience has long since shown the weakness of our art in such cases, and 
for that reason avoid such a degree of interference as might possibly 
abridge the little span of life allowed the patient by this relentless malady. 

Prophylactic Treatment. — It must be evident that the prophylactic 
treatment is of especial importance in a disease so little amenable to cura- 
tive means as the one under consideration. When, therefore, there is 
reason to suspect a tendency to tubercular meningitis in a child, either 
from the fact that other children in the family have perished with it, or 
from a bad state of the general health and frequent complaints of head- 
ache, it becomes proper and necesssary to regulate both the moral and 
physical education with a view to its prevention. For this end the Irygienic 
management of the child ought to be such as is best calculated to prevent 
the formation or development of tubercles in the constitution. During 
infancy, such a child should be nursed, if this be possible, by a strong, 
hearty woman, with an abundant flow of milk. If the mother is not pos- 
sessed of these qualities, if there be, indeed, the least doubt upon the 
point, she ought without hesitation to give up the pleasure of nursing the 
child herself, and procure for it a wet-nurse of the kind described. This 
alone will, in all probability, often make the difference between a vigor- 
ous and fragile constitution. When the time for weaning arrives, the 
change ought to be made wdth the greatest care and circumspection. 
During and for some time after weaning, the diet must consist principally 
of milk preparations and bread, and of small quantities of light broths, 
or of meat very finely cut up. As the child grows older, the meals ought 
to be arranged at regular hours, and should consist of four in the day. 
The principal food must be bread and milk, well-chosen, well-cooked 
meats, and rice and potatoes as almost the only vegetables. After the 
first dentition is completed, a moderate use of ripe and wholesome fruits 
may be allowed, but always with care, in order to avoid injury to the 
digestive organs, and also so as not to mar the appetite for more whole- 
some and nutritious food. Coffee and tea ought to be forbidden at all 
times ; since, as we have often observed, when the palate of a child is 
taught, by habit, to become accustomed to these more highly sapid sub- 
stances, it is very apt to abandon the use of milk, which ought to consti- 
tute a large proportion of its food, at least up to the age of twelve or fif- 
teen years. In no circumstances of life is the old saying, " where ignor- 
ance is bliss, it is folly to be wise," a better rule of action than in regard 
to the diet of our children. The child should not taste improper articles 
of food, so that it may escape the torment of desiring what is improper. 

After diet the most important points in the treatment are air and cloth- 
ing. The child should inhabit, if possible, a large, dry, well-ventilated 
room, which ought to be kept as cool as possible in summer, and moder- 



462 TTJBEBCULAB MENINGITIS. 

ately warm in winter. Not a da} T should be allowed to pass, unless the 
weather is totally unfit, without the child's being sent for several hours into 
the open air, and we believe that it is much better for it to walk than drive, 
unless the weather be very hot. The clothing ought to be suitable to the 
season, cool in summer and warm in winter. In our country there is a 
great inclination to harden children by dressing them very slightly in 
cold weather ; so that they frequently suffer from catarrh, pneumonia, and 
spasmodic croup, brought on by improper exposure. This cannot but be 
wrong in a child who shows the least evidence of a tendency to tubercular 
affections. 

For our own part we are fully convinced from what experience we have 
had of the diseases of children, that by far the most certain and effectual 
means of preventing the development of a tubercular, or indeed any other 
cachexia in a child, is to have it brought up in the open country, or in 
some healthy village, until the epoch of puberty has passed by safely. A 
very good plan for parents whose occupations compel them to live in cities 
or large towns, is to have their residence a few miles in the country and 
to come to town every day. Children brought up in this way have a far 
better chance of obtaining strong and vigorous constitutions, than those 
reared entirely in the close and confined dwellings and streets of crowded 
cities. 

When a child, who, from the health of its parents, or from its own ap- 
pearance, may be suspected of having anjr tubercular or scrofulous taint 
in its system, becomes subject to frequent attacks of apparently cause- 
less headache, and especially when such headaches are associated with a 
constipated habit of bod}^ and with occasional vomiting, it ought to be 
looked upon as threatened with tubercular disease of the brain. Under 
these circumstances we would advise, in addition to the measures just 
now recommended as to diet, dress, exercise in the open air, and a resi- 
dence in the country, that it be put at once upon the use of cod-liver oil, 
iodide of iron, and mild laxatives, and that these be persevered in for 
several weeks or months, until in fact the strength and general health are 
restored and the headaches cease. When the appetite is poor, and the 
digestion is imperfect, in such a case we may use with advantage, besides 
the above remedies, solution of pepsine, a teaspoonful three times a day 
with the meals, or tincture of mix vomica, three or four drops in a mix- 
ture of s^yrup and compound tincture of gentian, or in a teaspoonful of 
elixir of cinchona three times a day. If the child is of an age to be going 
on with its education, this should for the time cease, or be carried on in 
such a way as to avoid all excitement or fatigue. A case occurred to one 
of us in the course of the year 1852, which showed, we think, very clearly 
the utility of these measures. 

A boy between seven and eight years old, whose mother had died of 
well-marked phthisis a few months before he was put under our charge, 
had been losing flesh and strength, and suffering from occasional head- 
ache for some time before we were called to see him. We found him in 
bed complaining of severe frontal headache; so severe at times, and usu- 
ally in the after-part of the day, as to cause great distress, with crying. 



PROPHYLACTIC TREATMENT. 463 

The intelligence was perfectly natural. The child was rather dull and 
listless, from suffering and from weakness, but not from any want of a 
healthful state of the mental operations. There was no sign whatever of 
spasmodic or paralytic affection. In the morning the skin was cool and 
natural, but in the afternoon it became warm and dry, but not very hot. 
The pulse was 62 to 68, and though not actually irregular, it was halting 
or hesitating. There was occasional, but not frequent, unprovoked vom- 
iting, and he complained often of sick stomach, even when he did not 
vomit. The bowels were very much constipated, and had been a good 
deal so for some weeks previous to his falling actually sick. There was 
no cough, no sore throat, and no soreness about the abdomen. The 
tongue was moist, soft, slightly furred, and not red nor gashed. The 
urinary secretion was healthy. Physical examination showed the lungs 
and heart to be without disease. 

The treatment during the first week was small doses of calomel and 
rhubarb, half a grain of the former to two of the latter, given for a day, 
and followed by syrup of rhubarb and fluid extract of senna, until the 
bowels were copiously evacuated. After this the bowels were kept soluble 
by the administration every day, or every other day, of doses of Selzer 
powder, sufficient to produce the effect. Blisters were applied behind 
the ears. In the after-part of the day, when the head and body became 
heated, cooling applications were made to the head, and the feet were 
put into mustard-water, once, twice, or three times. Two grains of 
iodide of potassium were ordered to be given three times a day. The 
diet was to be light but nutritious. It was to consist of bread and milk 
and a soft-boiled egg in the morning, 0} T sters or light meats with rice for 
dinner, and milk with bread in the evening. Of these he was to have any 
reasonable quantity that he might desire. Under this treatment he im- 
proved slowly, with occasional drawbacks for a week, when the iodide of 
iron was substituted for the iodide of potassium. The bowels continued 
very costive, requiring daily doses of the Selzer powder; the headaches 
diminished in frequenc}*, duration, and severity; the pulse went up to 72 
and 78, and became more free and even; the appetite had improved, but 
the child remained still very weak, pallid, and quite emaciated. After 
another week, as he continued to mend, and the stomach had become 
stronger, cod-liver oil was ordered in addition to the iron ; a teaspoonful 
was to be taken three times a day in a wineglassful of table-beer. As he 
gained strength, the amount and kind of food was increased. He was,, 
indeed, encouraged to eat heartily of plain and digestible substances. 

He now improved gradually in health. The headaches subsided, and 
finally ceased; the bowels became soluble; the appetite grew hearty and 
strong, and all feeling of nausea disappeared; he regained his strength, 
flesh, and color, so that at the end of two months we saw him looking 
quite fat and well. The iodide of iron and cod-liver oil were, however, 
to be continued for a month longer. He is now (1869) a young man in 
very good health. He has passed several years in German}' pursuing a. 
scientific education, and has returned lately to this country, and is about 
to marry. 



464 SIMPLE MENINGITIS. 

As to the particular means likely to be of service in preventing a direc- 
tion of the tubercular cachexia towards the brain, such as might produce 
tuberculosis of that organ, we have only to propose the course recom- 
mended by different writers, viz., to keep the head cool by not allowing 
it to be very warmly covered, and by keeping the hair short ; to keep the 
extremities warm ; to avoid stimulating the intellectual faculties to any 
considerable extent by education, until after eight or ten years of age ; 
and to use every means to preserve the general health in a sound and 
pure condition. Some recommend the long-continued emphryment of a 
powerful derivative from the brain, as a small blister on the arm or a 
seton in the neck. We think, however, that such remedies ought not to 
be used unless there are positive s} T mptoms of a tendency to cerebral dis- 
order. The caution not to interfere much by powerful local applications, 
with eruptions which nature may have thrown out upon the scalp, is, we 
believe, wise and prudent; though there can be no objection to the ad- 
ministration of suitable internal remedies with a view to their cure. 



ARTICLE II. 



SIMPLE MENINGITIS. 



Definition ; Synonymes ; Frequency. — By this term is understood 
inflammation of the membranes of the brain, independent of tuberculosis 
of those tissues, or of other organs of the economy. 

The disease was for a long time confounded with tubercular menin- 
gitis under the titles of water on the brain, dropsy of the brain, and 
acute lrydrocephalus. It has also been called arachnitis ; and more rarely 
phrenitis. 

Its frequency is much less than that of tubercular meningitis. West 
>(op. cit., 4th Amer. ed., p. 100), states that he has seen T cases of fatal 
acute meningitis, in 5 of which post-mortem examination was made and 
confirmed the diagnosis. Yogel (op. cit., p. 359) speaks of it as being- 
much rarer than the tubercular form, and states that it is no more frequent 
in children than in adults. It appears that MM. Rilliet and Barthez, 
during their researches, met with only five cases of this disease, while 
they report thirty-three of tubercular meningitis. Bouchut states that he 
has met with two cases of simple meningitis to six of tubercular disease, 
whilst Barrier reports only four of the former in nearly thirty autopsies 
of meningitis. He states, however, that he has met with three cases of 
recover}^, all of which he believes to have been instances of the simple 
form. Fabre and Constant met with nine cases of simple to twenty-seven 
of tubercular meningitis in a period of two years, at the Children's Hos- 
pital of Paris. (Bibliotheque du Med. Prat., t. vi, p. 166.) 

Causes. — The causes of simple meningitis are not very clearly ascer- 
tained. It would appear, however, that the disease is more common in 



ANATOMICAL LESIONS. 465 

infants than older children. M. Rilliet, who published a very valuable 
paper on this affection (Arch. Gen. de Med., t. xii, 1846), divides it into 
two forms, the convulsive and phrenitic, the former of which he believes 
to be most common under two, and the latter between five and fifteen 
years of age. This author is disposed to think, from the fact that the 
disease is most frequent in the first and ninth years of life, that the pro- 
cess of dentition has something to do in its production. It appears also 
to be more frequent in bo} T s than girls, and in robust than in weak con- 
stitutions. Guersant has known it to follow long-continued exposure to 
the sun in several instances, particularly in 3 T oung infants ; MM. Rilliet 
and Barthez report a case of the same kind, and Rilliet (loc. cit.) another; 
other causes cited b3 r authors are injuries upon the head, such as blows, 
falls, and wounds. It also occurs as a consequence of extension of in- 
flammation to the membranes of the brain, and usually from the internal 
ear in cases of otorrhcea. 

The disease sometimes occurs in an epidemic form. 

Anatomical Lesions. — The dura mater is generally much injected, 
and its sinuses, together with the large cerebral veins, contain coagulated 
or semi-coagulated blood, sometimes in large quantities. On opening the 
dura mater, the whole, or nearly the whole of the convex surface of both 
hemispheres, or in some instances of one only, are found to be covered 
with a yellowish or greenish-3 T ellow layer, which consists of fluid or con- 
crete pus, or of false membranes. These deposits exist also on the inter- 
nal surfaces of the hemispheres, on the upper surfaces of the cerebellum, 
and often also at the base of the brain, though in some cases the latter 
presents none whatever. The inflammatory products are seated in the 
pia mater, and sometimes in the cavity of the arachnoid membrane, but 
in much smaller quantity than in the tissue beneath that membrane. 

The arachnoid membrane which covers the brain seldom participates 
in the inflammation, but remains smooth and transparent. Its cavity, 
however, sometimes contains inflammatory products, which, when death 
occurs early in the attack, consist of a small quantity of pure pus, or of 
larger quantities of a turbid, yellowish serosity, consisting of serum and 
pus mixed together. When death has occurred later in the disease, — 
after five, six, or seven days, — the pus is mixed with lymph, or else 
true false membranes are found. The pia mater is observed to contain 
fluid or semifluid pus when death occurs before the fourth or fifth day, 
while in less acute cases there are patches or large laj^ers of lymph, which 
sometimes dip into the anfractuosities, and give to the membrane under 
consideration a swelled and thickened appearance. These appearances 
are more marked on the superior and lateral, than on the inferior surface 
of the brain. Where the deposits exist the membrane presents a vivid 
injection, which is more marked in proportion as death has taken place 
earlier in the disease. The pia mater is generally easily detached from 
the cerebral substance, particularly when the fatal termination has oc- 
curred early. The substance of the brain is firm, and but slightly colored, 
in rapid cases. When the course of the disease has been slower,, the cin- 
eritious portion is generally of a bright rose color, and the medullary 

30 






466 SIMPLE MENINGITIS. 

substance abundantly dotted with red, showing that the inflammation has 
involved the superficial la}'er of the brain. In the latter class of cases 
the surface of the convolutions is usually softened, and the pia mater ad- 
herent. In very } T oung children the whole brain is sometimes soft. 

The venti*icles do not, as a general rule, contain transparent serum, 
except at a very early age, when serous effusion takes place with great 
facilitj". They often, however, contain one or two teaspoonfuls, and 
rarety more than one or two tablespoonfuls, of pus or purulent sernm. 
The serous membrane of the ventricles and the plexus choroides exhibit 
signs of inflammation in some instances. The} T are of a bright red color, 
uneven, rough, and very much softened, in children who die early; and 
pale, opaque, slightly thickened, and rough, in those who die at a later 
period. 

The central parts of the brain often retain their firmness, but are some- 
times softer than natural, or even diffluent. This softening is particularly 
apt to exist in very 3 T oung children, in connection with large effusion into 
the ventricles ; though it also occurs in those who are older, and in whom 
there is only slight effusion of pus or purulent serum. In the former 
case it is probably due to the macerating effect of the effusion, while in 
the latter it is more likely to be owing to inflammation. 

In some cases, and especially those of the epidemic form of the dis- 
ease, the membranes of the spinal cord are found to present the same in- 
flammatoiy appearances which have been described as existing in the 
cerebral meninges. These cases are, therefore, more correctly designated 
by the name cerebro-spinal meningitis. 

The other organs are healthy except in secondary cases. Tubercles, 
which so constantly exist in various other organs in tuberculosis of the 
meninges, are never found, according to M. Rilliet, in this form of men- 
ingitis. This author believes himself entitled from his researches to 
formulate the following law of pathological anatomy: "That general 
meningitis and meningitis of the convexity of the brain occur only in 
non-tuberculous children, whilst meningitis of the base of the brain, with- 
out inflammation of the lining membrane of the ventricles, belongs ex- 
clusively to tuberculous children." (Loc. cit., t. iii, 1846, p. 408.) 

This law cannot, however, be adopted without exception, since we have 
alread}' seen, when speaking of tubercular meningitis, that there are, in 
a large proportion of such cases, evidences of inflammation of the lining 
membrane of the ventricles. 

Symptoms. — The following account of the sjunptoms of the disease is 
taken chiefly from the paper of M. Rilliet. That author describes two 
forms of the affection, the convulsive and phrenitic ; the former of which 
is characterized by a predominance of convulsive phenomena, and the 
latter by disorders of the intelligence. 

The disease may also be idiopathic or secondar} T , simple or compli- 
cated, sporadic or epidemic. 

The convulsive form generally occurs in children under two 3 r ears of 
age. The disease usually begins suddenly or after a restless night, with 
a violent and prolonged attack of convulsions, oftener general than par- 






SYMPTOMS. 467 

tial, and is accompanied hy violent fever, and sometimes by considerable 
quickness of respiration. The existence of headache cannot be ascer- 
tained at this early age. Vomiting is often absent, and the bowels gen- 
erally continue regular in this form, though the} T are sometimes consti- 
pated. After a while the convulsions cease, and the child remains for 
the time in a state of quiet, somnolence, or coma, when they return with 
renewed violence. The returns of the convulsions generally take place 
at intervals of one or two hours or more. In the intervals between the 
crises the child is restless or drowsy, or in a state of partial stupor, at- 
tended with tremulous movements of the extremities; there is strabismus, 
contraction of the pupils, trismus, and sometimes hemiplegia. The skin 
retains its warmth, the pulse is accelerated, irregular, and unequal; the 
face is pale ; the stools are spontaneous or easily procured by remedies. 
It is unusual to see the child regain its consciousness so as to recognize 
objects in the intervals between the convulsions, or after the appearance of 
coma and other cerebral symptoms. Death occurs during coma or in a vio- 
lent attack of convulsions. This form seldom lasts more than four days. 

Occasionally this form begins in a different manner. The convul- 
sions, though t\\Qj still predominate, do not occur until later in the 
disease, and the whole course of the affection is slower. Such cases 
begin with a violent febrile movement, lasting several da} 7 s, and accom- 
panied by acceleration or unevenness of the respiration, or by almost con- 
stant drowsiness, preceded or followed by agitation, screaming, staring 
expression of the eyes, and dilatation of the pupils ; vomiting and con- 
stipation are sometimes present, at others absent. After a time, how- 
ever, convulsions make their appearance, and the case follows the course 
already described. The duration of this form may be the same as that of 
the first, or it may last about two weeks. 

The phrenitic form of simple meningitis generally begins suddenly 
with fever, which is sometimes preceded by a chill ; the skin is warm and 
dry, and the pulse, in idiopathic cases, full and accelerated. In secondary 
cases the pulse has been found slow and irregular ; in all it becomes irregu- 
lar, small, and very rapid the day before death. Simultaneously with 'the 
fever there is frontal headache, which is often so violent as to draw cries 
from the child, and, according to M. Rilliet, is more severe than either in 
tubercular meningitis or typhoid fever. It is also more constant, and 
lasts generally one, two, or three days, until the appearance of restless- 
ness, delirium, or coma. At the same time there is great sensibilhVy to 
light and noise, and abundant vomiting of bilious matter. The latter 
symptom is one of the earliest; it generally ceases after a few days, but 
sometimes continues to the very end. Constipation exists in some cases, 
but is much less constant and more easily overcome than in the tuber- 
cular disease. The appetite is lost, and the thirst very acute. The abdo- 
men is flattened and retracted, especially towards the end, while in sec- 
ondary cases of this form, and in very young children, it retains its usual 
shape. 

About the end of the first day, generally, or, in rare instances, after 
two or three days, appear various disorders of the intelligence. The first 



468 SIMPLE MENINGITIS. 

symptom of this kind is observable in the expression of the face, which 
becomes a little wild or wandering, and sometimes grimacing. Soon after- 
wards occur restlessness, which is sometimes extreme, and, in succession, 
delirium, somnolence, and later in the attack, coma. The restlessness 
and somnolence often alternate early in the case, though the former gen- 
erally predominates and soon passes into delirium, which is usually vio- 
lent. When in this condition the child seldom recognizes an}' one, and 
either refuses to answer questions, or answers incoherently. In connec- 
tion with the disorders of intelligence there exist also trismus, grinding 
of the teeth, subsultus tendinum^ partial convulsive movements, stiffening 
of the extremities or trunk, retraction of the head, strabismus, contrac- 
tion first and then dilatation of the pupils, and in some cases violent con- 
vulsions, followed Irv deep coma. Death sometimes occurs at this period. 
In other instances, the disease continues longer, and other symptoms 
declare themselves. Yomiting generally ceases ; constipation increases ; 
the abdomen is retracted ; headache is no longer complained of; the fever 
continues, but the pulse becomes irregular; the respiration is uneven and 
irregular, being sometimes more and at other times less frequent than 
natural; the face is distorted and extremely pale, or there maybe a purple 
flush on the cheeks ; the restlessness is excessive, and accompanied b} T 
subsultus, carphologia, or partial convulsive movements ; the delirium, at 
first so violent as to make it necessary sometimes to hold the child in bed, 
subsides into a state of coma and collapse, in which general sensibility is 
obtundecl, and special sensibility extinguished; the respiration becomes 
stertorous, and at length asphyxia, coma, or a severe attack of convul- 
sions terminates the scene. 

The course of the disease is generally continuous. In veiy rare cases, 
however, occasional remissions occur, so that the child recovers its intelli- 
gence for a short time, and recognizes persons around. The duration has 
varied between a day and a half and nine da} T s. 

Diagnosis. — The convulsive form ma}^ be confounded with the essential 
or s3*mptomatic, and with the sympathetic convulsions of children. The 
mistake may general^ be avoided by attention to the following points. 
In essential convulsions, the attacks are usually less violent, seldom last 
more than a few moments, occur from some evident cause, and do not 
recur often. When the}^ have ceased, the child generally soon regains its 
consciousness and health, or exhibits slight drowsiness, or derangement 
of movement for a short time only. In such cases the respiration is not 
permanently accelerated, as in convulsive meningitis ; the pulse, if it had 
been increased in frequenc}^ soon falls to the natural standard, and spe- 
cial sensibility remains undisturbed. 

It is to be distinguished from sympathetic convulsions b3 r the characters 
just described, aided by a reference to the disease which may have caused 
the attack of eclampsia, and which maj r be one of the eruptive fevers, 
enteritis, indigestion, pneumonia, or any other acute affection. In some 
instances, however, the distinction cannot be made except by attention 
to the progress of the attack. 

The phrenitic form may be confounded with tubercular meningitis, 



DIAGNOSIS — PROGNOSIS — TREATMENT. 469 

with congestion of the brain, or with the early stage of the eruptive fevers. 
The distinction between it and tubercular meningitis has already been 
considered under the head of the latter disease. 

M. Killiet is of opinion that it is sometimes impossible, in the present 
state of knowledge upon these points, to distinguish with certainty be- 
tween simple meningitis and cerebral congestion or hemorrhage, and en- 
cephalitis. In regard to congestion of the brain, he proposes the very 
important question, ;; Whether we ought to class as meningitis the dan- 
gerous cerebral symptoms, resembling exactly those which mark the 
commencement of meningeal inflammation, and terminating rapidly by 
death or recovery?" He states that examination after death in these 
cases reveals neither pus nor false membranes in the arachnoid or pia 
mater, but simple congestion of the brain and its membranes. He deems 
the solution of the question to be difficult, but is himself of opinion that 
they ought not to be classed together. He gives the following table, 
which he thinks may assist in making the diagnosis : 

CONGESTION OF THE BRAIN— MODE OP MENINGITIS. 

INVASION. 

There occurs instantaneously profound In the phrenitic form the first symptom 
stupor, absolute immobility and insensi- is generally headache, which is not noted 
bility, with dilatation of the pupils; or else in any of the cases of M. Bland (of con- 
acute delirium, with difficulty of breath- gestion). The alterations of intelligence 
ing, and with acceleration and smallness and motion occur early, but not before the 
of the pulse; or in yet another class of beginning of the first or second day; 
cases with tremors or slight convulsive whilst in congestion, the appearance of 
movements of one side of the body. Stut- delirium or coma, of subsultus tendinum, 
tering, loss of speech, stertorous respira- or partial paralysis, is instantaneous, 
tion and pains in the arms and corre- frightful, truly apoplectic, and, so far as 
sponding side of the face exist ; the fingers we can ascertain, not accompanied by 
do not retain objects which the child at- vomiting, — a symptom rarely absent in 
tempts to grasp. meningitis. 

From the invasion of variola, it is to be distinguished by attention to 
the contagious and epidemic nature of that malady, by the inquiry as to 
whether the patient has been vaccinated or has had a prior attack of that 
disease, by the absence of pains in the loins, in meningitis, and by a con- 
sideration of the period at which the delirium makes its appearance, 
which, in variola, rarely occurs before the third day. To make the diag- 
nosis between meningitis and malignant scarlatina, we must attend chiefly 
to the epidemic and contagious character, to the thick coating upon the 
tongue, redness of the throat, elevated temperature, and nasal respira- 
tion, which exist in the latter. 

Prognosis. — The prognosis of simple meningitis is very grave, but 
much less hopeless than in the tubercular form. M. Talleix is disposed 
to think that most of the recoveries reported by M. Guersant were cases 
of sanguine congestion or effusion. M. Rilliet {loc. cit.), who has studied 
the subject more carefully than any other observer, cites several instances 
of recovery, but states that death is much the most frequent termination. 

Treatment. — It must be evident, it seems to us, that but little depen- 



470 SIMPLE MENINGITIS. 

dence can or ought to be placed on any but prompt and powerful anti- 
phlogistic treatment. Bloodletting, therefore, mercury, cold applications 
to the head, purgatives, counter-irritants, and the most rigid diet ought 
to be employed from as early a period as possible, and in the most ener- 
getic manner. 

Venesection ought always to be preferred to local bleeding, even in the 
youngest child, unless it is impossible to find a vein, or unless this is 
evidently too small to bleed well. When venesection cannot, from any 
reason, be empkyecl, blood should be freely drawn by means of leeches 
or cups. It is customary to apply the leeches to the temples or behind 
the ears. We may remark that MM. Rilliet and Barthez object to the 
application of leeches to the head, and propose that they should be placed 
rather about the anus or on the inferior extremities. The quantity of 
blood to be drawn must depend upon the age and constitution of the 
subject, and the violence of the attack, in some measure. It should al- 
ways, however, be large, as much or more, we think, than what is neces- 
saiy in any other of the acute affections of childhood. In a child two years 
old, of good constitution, from two to four ounces would not be too much 
at first, and should the sj^mptoms not moderate in six or eight hours, as 
much more may be taken. . Should these detractions of blood fail to pro- 
duce a good effect upon the dangerous symptoms, it would be proper, 
unless there were evident and unmistakable signs of exhaustion, to take 
still more, either locally or generally. We are disposed to believe that 
in such a disease as this, bleeding is by far the most powerful remedy, 
and it is perhaps the only one which offers us any real chance of success, 
at least in those rapid cases in which extensive la} T ers of pus and false 
membranes are found on the surface of the brain, in the pia mater, or in 
the subarachnoid tissue, in from two days and a half to three or four days 
after the commencement of the disease. 

While the bleeding is being performed we should direct the prepara- 
tion of means for the application of cold to the head, which constitutes 
another most efficient remedy in inflammations of the brain and its mem- 
branes. These means may consist of a bladder containing water and 
pounded ice, which is perhaps the most convenient and powerful, of 
cloths wrung out of iced or very cold water, to be constantly renewed, 
of cold affusions upon the head, or, lastly, of irrigation as recommended 
by M. Guersant, and described in the article on tubercular meningitis. 
Purgatives ought to be empkyed so as to empty the bowels thoroughly, 
and produce a decided revulsion upon the intestinal mucous membrane, 
but not in such quantity as to occasion inflammation of that tissue, 
which would be very apt to prove the case were the drastic substances 
and large doses recommended by some writers used. The remedy usually 
given and most highly recommended is calomel, which is chosen for its 
sedative and alterative properties. About four grains may be exhibited 
alone, and followed in one, two, or three hours by castor-oil, jalap, or in- 
fusion of senna and manna, sweetened with syrup of rhubarb. These 
doses ought to be given until the bowels are freely moved. It is alwaj*s 
useful to employ a strong purgative enema immediately after the bleed- 



CEREBRAL CONGESTION. 471 

ing, without waiting for the operation of the internal remedies. After 
the purgative doses have been given, it is important to continue the mer- 
cury in smaller quantities, with the view of obtaining its specific influence 
upon the inflammation. The doses may consist of from a quarter of a 
grain to a grain every hour or two hours. Some writers also recommend 
very highly the use of mercurial inunction. Yogel (op. cit., p. 361) states 
that a mercurial treatment is decidedly effectual, and adds that the only 
two children he has seen recover from this disease, were treated exclu- 
sively with mercury, internally and externally. 

Counter-irritants are useful as adjuvants to the more powerful remedies 
already indicated. During the first da} T or two they should consist chiefly 
of sinapisms and mustard poultices, applied from time to time to the 
trunk and extremities. Authorities differ somewhat as to the effect of 
blisters, and as to the time at which they ought to be applied. M. Yal- 
leix (loc. cit., t. ix, p. 181), opposes their employment in this affection as 
often injurious and still more frequently useless. We think the advice 
given by Dr. Abercrombie, as to their employment, is probably the most 
prudent. This is, not to apply them in the early stage, but to wait until 
the active symptoms of the disease have been subdued. They may be 
applied to the head itself, to the nucha, or to the extremities. We be- 
lieve that we have seen them most useful when applied to the neck and 
insides of the calves of the legs. Nevertheless, there is high authority in 
favor of their good effects when applied upon the head itself. 

M. Eilliet (loc. cit.) recommends a vigorous revulsion upon the scalp 
when the disease has followed the suppression of an eruption. He pro- 
poses with this view the employment of pustulation by croton oil, and 
relates a case of recovery which followed this treatment under a most 
unfavorable train of symptoms. To make use of it the head must be first 
shaved ; from fifteen to twenty drops of the oil are then to be rubbed over 
the scalp with a glove four or six times a day. Before making the fric- 
tion, the eyes of the patient must be covered with a band to prevent the 
introduction of any of the oil into them, as this would be apt to occasion 
severe ophthalmia. In the case reported by him, a considerable number 
of pustules were produced in twenty-four hours, and in a few more hours 
the eruption was general, so that the head was covered with a kind of 
cap of a fine yellow color. 



ARTICLE III. 

CEREBRAL CONGESTION. 

We believe, from our personal observation and from the evidence of 
several of the highest authorities on the diseases of children, that cerebral 
congestion is of rare occurrence as an idiopathic and distinct affection in 
early life. We think that the symptoms which are detailed in this article, 
and which are by several writers, and especially by Dr. West, attributed 



472 CEREBRAL CONGESTION. 

to congestion of the brain, are rather due in some cases to mere excite- 
ment and undue rapidity of the circulation, and in others to the irritation 
of the brain, caused by the circulation through it of a blood vitiated by 
the poison of some of the acute specific diseases. In other instances 
still, we think the attacks are more accurately included under the title of 
eclampsia. 

In support of these views we quote belovr the opinions of some of the 
authors referred to. MM. Rilliet and Barthez assert (lere edit., t. i, p. 
649) that the}' have found in children dying of different diseases, and 
who had presented no cerebral symptoms, congestion precisely similar 
to what they found in others who had exhibited more or less dan- 
gerous idiopathic or secondary nervous Sjmiptoins. " Some patients," 
they remark (loc. cit, p. 650), "it is true, who presented us with exam- 
ples of cerebral Iryperreniia, had had well-marked nervous sjunptoms. 
Thus we have met with the anatomical characters of congestion in young 
subjects who had perished with convulsions, in those whose sickness had 
been accompanied b}^ violent delirium, and in others who, in the course 
of scarlet fever for instance, had been seized with nervous symptoms. 
But, on the other hand, we have met with a nearly equal number of pa- 
tients who had died under the same circumstances, but in whom the 
cineritious and medullaiy substances preserved their usual color, and the 
pia mater was not injected. What are we to conclude from these facts? 
Most assuredly that we ought not to attribute to cerebral hyperemia any 
considerable part in the production of the sj^mptoms." At page 651 they 
say : " The most important practical point is in fact to determine whether 
it is possible to recognize cerebral congestion in a child by special and 
characteristic symptoms, and whether we ought as a consequence to pre- 
scribe a particular form of treatment. We acknowledge, on our part, 
that we find it impossible to describe any symptoms peculiar to that con- 
dition, and consequently to formulate a treatment." In the article on 
convulsions (t. ii, p. 281) they state that in some of their patients they 
found no traces of congestion, and add that eclampsia is sometimes (a 
well-known fact) connected with an anaemic state of the brain. "What 
are we to conclude from these opposite facts, if it be not that congestion 
plays but a secondary part in convulsions?" The}' coincide in opinion 
with the authors of the Compendium, who suppose that the congestion 
found in patients who have died with convulsive S}'mptoms, is generally 
the effect and not the cause of the convulsions. They do not den}', how- 
ever, that a suddeu congestion of the brain may produce a convulsive 
attack, and quote cases from other writers. 

We believe it to be a very common opinion in this country that most 
of the nervous symptoms (delirium, somnolence, coma, convulsions, &c.) 
which occur in the course of many of the diseases of childhood, depend 
chiefly upon a congested condition of the nervous centres, and many 
practitioners refer most of the cases of eclampsia of children to the same 
cause. We are glad, therefore, to call the attention of the profession to 
this point, and to place before it the opinions of some of the recent dis- 
tinguished authorities in regard to it. 



GENERAL REMARKS. 473 

The authors of the Bibliotheque du Med. Prat, are of opinion that it is 
very rare to meet with true pathological and idiopathic congestion of the 
brain, either in the first or second infancy (t. vi, p. 118). M. Barrier 
states that primary or second ary hyperemias are sometimes a cause of 
convulsions, and that such cases are the most dangerous of their kind. 
He also states that in rare instances congestion assumes a more men- 
acing character, similar to that which is more frequently met with at an 
advanced age. meaning the apoplectic form. M. Yalleix asserts (op. 
cit., t. ix, p. 259) that "cerebral congestion is a disease almost unknown 
in infancy." 

M. Rilliet, in the paper on simple meningitis quoted in the article on 
that disease, states, as his opinion, that the cases attended with dangerous 
cerebral symptoms, which resemble exactly those occurring at the com- 
mencement of meningeal inflammation, which terminate rapidly in death 
or recoveiy, and in which the only lesions found after death are conges- 
tion of the brain and its membranes, ought to be regarded as dependent 
upon congestion, though he thinks it difficult to determine positively 
whether they are in fact the result of that condition, or whether they are 
not merely the forming stage of meningitis. 

Dr. Charles West, of London, whose publications upon the diseases of 
children are amongst the most valuable that the English press has afforded 
us, treats of congestion of the brain in children as a very important and 
frequent condition of disease. We shall chiefly follow him in our remarks 
upon this subject, although we have no doubt, from our own observation 
and from the researches of the French observers above quoted, that its 
importance has been much exaggerated, and that its real influence in 
the production of the symptoms generally ascribed to it is very imper- 
fectly understood. 

Dr. West treats of congestion of the brain under two heads, as active 
or passive. By the former is meant the kind of congestion occurring 
under the influence of a cause which greatly increases the flow of blood 
to the head, and to this class belong, for instance, the head symptoms 
which often usher in the eruptive fevers ; by the latter is understood the 
kind depending on an impediment to the reflux of blood from the brain, 
to which belong for example, the convulsions which occur in a fit of hoop- 
ing-cough. 

Active congestions may occur during the process of dentition, or may 
result from exposure to the sun, or from blows upon the head ; passive 
congestion may be the result of a mechanical impediment to the return of 
blood from the brain, as the pressure of an enlarged thymus, or it maybe 
the result of enlarged and tuberculous cervical or bronchial glands press- 
ing upon the jugular veins, or of languid circulation depending upon want 
of pure air, or of nourishing and sufficient food. Dr. West states that in- 
tense cerebral congestion is not a very unusual consequence of the disturb- 
ance of the circulation at the outset of the eruptive fevers. He says that 
convulsions and apoplectic S3 r mptoms sometimes come on suddenly in 
these cases, and may terminate fatally in less than twenty-four hours : after 
death "the brain is found loaded with blood, but all the other organs of 



474 CEKEBRAL CONGESTION. 

the body are quite healthy." We would merely remark here, that it seems 
to us very doubtful whether the nervous symptoms just alluded to, ought 
not to be regarded as the result of the presence in the nervous centres of 
a diseased and vitiated blood, rather than of congestion. That conges- 
tion does not alwa} T s produce them is shown hy the statement of MM. 
Eilliet and Barthez (op. c?Y., t. ii, p. 620), in regard to the cerebral symp- 
toms of scarlet fever, " that a more or less marked sanguine congestion 
(of the cerebrospinal apparatus) is the only alteration generally but not 
ahvays found ; and sometimes the congestion is not more marked than in 
other diseases in which there had been no cerebral symptoms." With 
these remarks we shall pass on to the consideration of the symptoms 
generally ascribed to congestion occurring under other circumstances, as 
those taking place in the course of the eruptive fevers will be treated of 
under the head of those affections. 

Dr. West states that cerebral congestion may come on suddenly with 
very alarming symptoms, or it may be preceded for a few dsijs by general 
uneasiness, b}^ a disordered state of the bowels, generally but not alwa} T s 
consisting of constipation, and b}^ peevishness. " The head by degrees 
becomes hot, the child grows restless and fretful, and seems distressed 
by light or noise, or sudden motion, and children who are- old enough 
sometimes complain of their head." Yomiting generally occurs repeat- 
edly, sometimes before any other symptoms, and is a very important sign. 
The fever varies greatly as to its violence, though the pulse is usually 
much and permanently quickened, and if the skull be still unossified, the 
anterior fontanelle is either tense and prominent, or the brain is felt and 
seen to pulsate forcibly through it. The sleep is disturbed, the child 
often waking with a start, and there is often occasional twitching of the 
muscles of the face or the tendons of the wrist. 

The child, Dr. West remarks, may recover from these symptoms with- 
out any medical interference, or the case may become aggravated and 
terminate in acute hydrocephalus ; or again, the congestion maj r increase 
and cause the following symptoms. Under the latter condition, "the 
countenance becomes heavy and anxious, the indifference to surrounding 
objects increases, and the child lies in a state of torpor or drowsiness, 
from which, however, it can at first be roused to complete consciousness." 
The bowels generally continue constipated, and the vomiting seldom 
ceases, though it ma}' be less frequent. The pulse is usually smaller than 
before, and often irregular in its frequencj r , though not intermittent. 
" An attack of convulsions sometimes marks the transition from the first 
to the second stage ; or the child passes, without any apparent cause, from 
its previous torpor into a state of convulsions, which subsiding, leaves 
the torpor deeper than before. The fits return, and death may take place 
in one of them, or the torpor growing more profound after each convul- 
sive seizure, the child at length dies comatose." 

This second stage is usually of short duration, as death generally oc- 
curs, unless relief be afforded by appropriate treatment, within forty-eight 
hours from the first fit, " though no graver lesion maj T be discovered after- 
wards than a gorged state of the vessels of the brain and its membranes, 



CEREBRAL HEMORRHAGE. 475 

and perhaps a little clear fluid in the ventricles and below the arachnoid." 
Occasionally, however, recovery takes place, contrary to all expectation, 
after these symptoms have continued but slightly modified, for clays or 
even weeks. 

Acute congestion is to be treated like simple meningitis, with blood- 
letting, cathartics, calomel, cold applications to the head, baths, revul- 
sives, low diet, and confinement to a cool, dark chamber. It is useless 
to repeat here, what has already been said in our remarks upon the treat- 
ment of meningitis. 

In passive congestion the treatment should consist, according to Dr. 
West, of careful local depletion, if the case will bear it, and in strict 
attention to the diet and state of the bowels. He recommends mercury 
and chalk, to correct the bowels when they are out of order. If the case 
be associated with diarrhoea and bad nutrition, he recommends that ex- 
tract of bark, with a few drops of sal volatile, or of the compound tinc- 
ture of bark, be given two or three times a clay. Farinaceous food, he 
remarks, is not usuahy well digested when nutrition is much impaired, 
and he recommends milk and water, or milk and water with isinglass, or 
veal-tea. 






AETICLE IV. 

CEREBRAL HEMORRHAGE. 

We shall consider hemorrhage of the brain under two heads, that of 
the substance, and that of the membranes ; the former is usually desig- 
nated as cerebral, and the latter as meningeal apoplexy. Both these 
forms of hemorrhage are of rare occurrence in childhood compared with 
other diseases of the brain, and with their frequency during adult life 
and old age. Of the two kinds, that of the meninges is the most common. 

•Definition ; Frequency ; Forms. — By cerebral apoplexy or hemor- 
rhage is understood an effusion of blood into the substance of the brain. 
By meningeal apoplexy or hemorrhage is understood an effusion of blood 
between the dura mater and cranium, into the cavity of the arachnoid 
membrane, beneath the arachnoid, or in the meshes of the pia mater. 
Cerebral hemorrhage is a very rare affection in childhood. This is proved 
to be the case by the facts that MM. Rilliet and Barthez met with only 
eight cases in their extensive experience, and that M. Barrier saw but 
one in 5*76 cases of disease of all kinds. Meningeal apoplexy is of more 
frequent occurrence, since MM. Rilliet and Barthez report eighteen cases. 
M. Barrier met with one case of this form in the 576 cases referred to. 
Dr. West (London Med. Gaz., June 18th, 1847, p. 1062) says he has only 
twice met with distinct extravasation of blood into the substance of the 
brain in children. 

Hemorrhage into the substance of the brain occurs in two different 
forms : one in which the effused blood is contained in a cavity caused by 



476 CEREBRAL HEMORRHAGE. 

a laceration of the tissue of the organ, and designated apoplexy in a 
cavity ; and the other in which the blood is effused in a multitude of little 
points of different sizes, and designated capillary apoplexy. 

In meningeal hemorrhage the blood may, as we have stated, be effused 
between the dura mater and the bone. This form, however, is veiy rare, 
so rare, indeed, that several writers deny its existence. It is proved, 
however, to have occurred, by a case reported by MM. Rilliet and Barthez, 
which is the only one they have met with. In by far the most common 
form of the disease, the blood escapes into the cavity of the arachnoid 
membrane. Of this form the authors just quoted report It cases, while, 
according to the authors of the Bibliotheque du Med. Prat. (t. vi, p. 193), 
the effusion alwa} T s occurs in this situation. That this is not invariably 
correct, however, is proved by the case of effusion exterior to the dura 
mater already referred to, and by the fact that it sometimes takes place 
beneath or in the meshes of the pia mater. The latter class of cases is 
very rare, however, in proportion to those in which the hemorrhage occurs 
within the cavity of the arachnoid. MM. Rilliet and Barthez did not 
themselves meet with a single instance of that kind, but they quote two 
from other writers ; and M. Yalleix refers to a memoir by M. Prus, in 
which others are given. It appears, therefore, that in the great majority 
of instances, the effusion takes place within the cavity of the arachnoid 
membrane. 

Causes. — The causes of cerebral hemorrhage are very obscure, so much 
so, indeed, that some writers have not attempted to ascertain them. They 
appear to be the same in both forms of the affection. Amougst the 
ascribed causes are the sudden disappearance of eruptions of the scalp, 
observed in two cases by MM. Rilliet and Barthez, in one of which this 
effect is stated to have been produced suddenly by medical treatment, 
while in the other it followed the application of poultices to a favous 
eruption upon the same part. This cause must, however, it appears to us, 
be regarded as purely illusory. The disease is stated by M. Legendre to 
have followed in one case a violent fit of auger. It is said also to have 
been produced b}^ various causes which acted as impediments to the cir- 
culation. The obstacle may be situated within or exterior to the cranium. 
To the first class belong cases in which the sinuses and large venous 
trunks of the head have been found obstructed by coagula of blood, or 
by the pressure of tumors, generally of a tubercular nature ; to the latter, 
those in which there is intense engorgement of the superior cava pro- 
duced, as in prolonged parox3 T sms of hooping-cough, or in obstructive 
cardiac disease, or where, there is compression of this vessel by enlarged 
and tubercular bronchial glands. Another cause is thought to be the ex- 
istence of confirmed cachexia and general debility from any diseased 
condition whatever, in which the blood having become thin and lost its 
plasticity, escapes from the vessels with great facilit}\ This last condi- 
tion is one which almost alwa3 T s exists in connection with the causes cited 
as acting through the agency of obstruction to the circulation, and tends 
of course to augment their dangerous effects. 



ANATOMICAL LESIONS. 477 

In some instances the hemorrhage occurs in the healthiest and most 
vigorous constitutions, and cannot be accounted for in airy way. 

It appears that meningeal apoplex}^ is most frequently met with in very 
young children, according to MM. Killiet and Barthez, between the ages 
of one and two and a half } T ears, whilst M. Legendre did not meet with a 
single case after three 3 T ears of age in 248 autopsies. Cerebral and ven- 
tricular hemorrhage, on the contrary, are much more common after three 
years of age than before, which is just the reverse of the law in regard to 
meningeal effusion. 

Anatomical Lesions. — The description of the lesions of hemorrhage 
into the substance of the brain need not detain us long, for they are much 
the same as those observed in the adult. When the blood is effused into 
cavities (apoplexy in cavities), the latter are usually small in size, seldom 
exceeding from one to two-thirds of an inch in diameter, though in rare 
cases they have been found much larger. The cavity is formed b} r a 
laceration of the substance of the brain, and is tilled with soft, dark 
coagula, or sometimes with fluid blood; the walls of the cavity consist 
sometimes of the substance of the brain, which may be of a rosy color 
and natural consistence, or yellowish and softened, while in other in- 
stances they are formed of more or less numerous points of capillary 
apoplexy. The capillary form of effusion occurs in the shape of a number 
of points, scarcely so large as the head of a small pin, and of a dark or 
brownish color, which contrasts strongly with that of the cerebral tissue. 
These points evidently consist of true coagula, which are sometimes sur- 
rounded by small yellowish areola?. The substance of the brain around 
the effusion is either white, firm, and perfectly healthy, or softened, and 
of a whitish, reddish, or yellowish color. The capillary effusions are 
generally limited within a space of from a third of an inch to an inch and 
a half in size, but they have been found scattered over a large portion of 
the hemispheres. 

Both forms of hemorrhage are much more common in the cerebrum 
than cerebellum, and occur more frequently on the left than right side. 
In addition to the sanguine effusion there is generally considerable con- 
gestion of the pia mater, of the venous sinuses, or of the substance of the 
brain itself. 

In describing the lesions of meningeal apoplexy, we shall confine our. 
remarks to the effusion which occurs into the cavity of the arachnoid, 
this being, as we have already remarked, by far the most frequent form 
of the disease. 

The appearances presented by the cavity of the arachnoid into which the 
effusion has taken place vary greatly in different cases, according to the age 
of the child, the quantity of the hemorrhage, and the period of time which 
may have elapsed between the accident and the death of the patient. It is 
very uncommon to find pure liquid blood, though this has been met with. 
In most instances, there is a bloody serum mixed with thin, reddish 
coagula, contained in a soft and very delicate membrane lining the in- 
ternal surface of the arachnoid. Sometimes the effusion is thin, limpid, 
and more or less yellowish in color, while at other times it is thick and 



478 CEREBRAL HEMORRHAGE. 

brownish, or chocolate-colored. In some rare cases it is perfectly trans- 
parent and colorless. The fluid, in whatever state it exists, appears to 
be the result of transformations undergone by the effused blood. The 
solid portion of the blood or clot is found either in the condition of more 
or less recent coagula, or changed into false membranes, which sometimes 
resemble very closely the arachnoid itself, and sometimes a true fibrous 
membrane. The coagula are found in the form of thin membranes, vary- 
ing between one or two lines in thickness, and an inch and a half or two 
inches in size. The} r are thickest generally in the centre, where they 
measure between a fifth of a line and two lines, and are brownish or green- 
ish in color, and of variable consistence, according to their age. These 
coagula may exist upon any portion of the brain, but, according to MM. 
Rilliet and Barthez, are most frequently met with upon its convex surface. 

The coagula just referred to undergo in some instances a curious change, 
of which we shall give a short description. In the course of time, the 
fibrinous portions of the blood are deposited upon the internal surfaces 
of the cavity of the arachnoid, in the form of a new membrane. When 
death occurs soon after the onset of the attack, the parietal layer of the 
arachnoid is found to be completely lined with this membraniform pro- 
duction, whilst the visceral or cerebral kyer is covered by it only in cer- 
tain points. When the case has lasted a longer time, on the contrary, 
the visceral as well as parietal layer of the arachnoid may be covered 
with the new production, and when this happens there is formed a true 
sac or c} T st, destitute of opening, which lines the whole interior of the 
arachnoid, and contains within its cavity bloody serum and coagula. At 
first this new membrane is reddish in color, elastic, and of a stronger 
texture than might be supposed from its apparent thinness and softness. 
Its thickness is generally about a tenth of a line. At a later period the 
walls of the c} T st become so thin and transparent, that they have been 
mistaken for the arachnoid itself. They differ, however, from the latter, 
in being rather less transparent and thin, and particularly in the circum- 
stance of presenting numerous arborizations. When death occurs at this 
stage, which M. Legendre (whose description we chiefly follow) calls the 
second period, or that of complete organization of the cyst, the external 
surface of the latter is found to adhere intimately to the parietal portion 
of the arachnoid membrane, b}^ very delicate cellular tissue, though not 
with so much force but that it may be detached by traction. The internal 
portion of the new membrane, on the contraiy, which is lubricated by the 
serosity of the arachnoid tissue, is very slightly adherent to the layer of 
that membrane covering the brain. 

So long as the cyst formed by the new membrane, or, as it is called by 
MM. Rilliet and Barthez, the pseudo-arachnoid membrane, contains an 
amount of fluid sufficient to keep its surfaces separated, its cavity is 
single. When, on the contrary, the walls of the cyst have come into con- 
tact, either because of the partial absorption of the contained fluid, or 
because the fluid has accumulated at the lowest points, or wherever there 
is the least resistance, the cavity becomes multilocular in consequence of 
the cohesion of its walls at certain points. 



CHANGES IN THE EFFUSED CLOT — SYMPTOMS. 479 

The size of the cyst varies exceedingly. Sometimes it covers the 
greater part of the convex surface of one hemisphere, sometimes the 
whole, while in other instances it extends to the base, forming in that 
case a nearly complete shell for the whole brain. The quantity of fluid 
varies in different cases. Sometimes it amounts only to a few large 
spoonfuls ; in others, to one or two, or eight or nine ounces: in one case 
observed by MAI. Rilliet and Barthez there was upwards of a pint on 
each side, or more than a quart in all. In most .instances the hemor- 
rhage occurs into both halves of the arachnoid membrane, so that there 
is a cyst for each hemisphere. More rarely it occurs only on one side. 

In the second stage, and when the effusion is very large, which rarely 
happens except in young children and prior to ossification of the fonta- 
nelles or sutures, the lesion constitutes a form of chronic external hydro- 
cephalus, and the symptoms are such as will be detailed under the head 
of this latter disease. The vault of the cranium is enlarged by the un- 
natural prominence of the frontal and parietal bones,; the sutures are 
more open than usual, and the anterior fontanelle is distended and pro- 
tuberant. When the effusion occurs thus early in life, before complete 
ossification of the skull, the brain does not appear compressed or flat- 
tened, as it does when the disease, occurs at a later period. 

The visceral portion of the arachnoid is often thickened, opaque, and 
more resisting than natural. The pia mater is frequently infiltrated with 
a good deal of seroshy, which sometimes has a gelatinous appearance. 
When death has occurred in the first stage of the disease, the brain 
usualby presents signs of hyperemia. The veins on the surface of the 
hemispheres are enlarged, the cortical substance is of a bright rose-gray 
color, and the medullary portion is dotted over with drops of blood. 
Sometimes the cellular substance beneath the arachnoid is slightly in- 
filtrated with serosity, at other times not. The ventricles contain a very 
small quantity of fluid. 

The exact anatomical cause of cerebral hemorrhage in children is still 
subject to some doubt. It appears probable that it usually results from 
intense determination of blood to the head or from extreme passive con- 
gestion, which lead to the rupture of such minute vessels as to escape 
notice, or possibly in some cases to the transudation of blood through the 
capillary walls without actual rupture. We are not aware that any careful 
microscopic examination has yet been made of the condition of the walls 
of the vessels in such cases. In some rare instances, however, as in one 
witnessed by M. Legendre, the effusion is the result of the rupture of a 
vessel of some size. In the case observed by him, death took place in 
twelve hours from the attack, and the left hemisphere was found covered 
with a layer of coagulated blood, which had escaped from a ruptured vein. 
{Biblioth. du Med. Prat., t. vi, p. 192.) 

Symptoms; Duration.: — The s3anptoms of hemorrhage into the sub- 
stance of the brain in the child are, as a general rule, extremely obscure 
and uncertain, though in some few cases that have been observed, they 
were as characteristic as those which occur in adults. In obscure cases 
the chief symptoms that have been noticed were restlessness, delirium, 



480 CEREBRAL HEMORRHAGE. 

headache, violent fever, grinding of the teeth, and, after a time, complete 
abolition of the intelligence, fixity of the eyes, invariable dilatation of the 
pupils, stertorous respiration, and general insensibility. Of three cases 
reported hj M. Yalleix (Clinique des Mai. des Enf.), the nature of the 
disorder was easily diagnosticated in one by the existence of complete 
hemiplegia, while in the two others, the only marked symptom was entire 
immobility. The only certain symptom of the disease, therefore, would 
be a sudden attack of hemiplegia, either as the primary symptom, or fol- 
lowing coma or convulsions, and lasting for at least several days. An 
attack of general paralysis would not be by any means so certain, as this 
may exist in several other diseases of childhood. 

In a case which came under our charge, we believe the attack to have 
been one of apoplexj^ of this kind. A girl, two years and a half old, 
apparently in the enjojmient of excellent health, was suddenly, and with- 
out ascertainable cause, attacked with violent general convulsions and 
entire insensibilhVv, which lasted with veiy slight remissions of the con- 
vulsive movements, but without any return of consciousness, for twelve 
hours. At the end of that time the convulsions ceased entirely, and she 
veiwsoon regained her consciousness, remaining merely peevish and lan- 
guid. She was, however, complete^ hemiplegic on the left side, so that 
she could neither rise in bed, nor turn towards the right side. The paral- 
ysis diminished rapidly, but regularly, so that at the end of three days she 
could sit up in bed, and in a few weeks was perfectly well. This child 
remained well, with the exception of rather unusual excitabilny, and some 
peevishness of temper, for three 3 T ears, when she died of scarlet fever. 
Ko autopsy could be made. 

The obscurity which exists in these cases will be clearly understood by 
any one who will read two examples given by Dr. West (loc. ciL, p. 
1062). 

With a short quotation from the work of MM. Eilliet and Barthez, we 
shall pass on to the subject of meningeal apoplexj\ These authors remark 
(op. cit., t. ii, p. 54), in speaking of this affection, that " cerebral symptoms 
have been observed to exist, but of so unusual a character, and so differ- 
ent from what have been assigned by writers to apoplexy, that they could 
not lead to a diagnosis of the disease." 

We shall describe the symptoms of the meningeal form of hemorrhage 
under two heads ; first, as they present themselves in the acute, and, 
second, as they occur in the chronic or second stage of the affection. 

Unfortunately the sj'mptoms of the acute or first stage are not much 
more certain and distinct than those of cerebral hemorrhage. The dis- 
ease may begin with fever and some convulsive movements, or, as hap- 
pened in a case reported by M. Yalleix, with violent general convulsions. 
Yomiting sometimes occurs at the beginning, but is usually very slight. 
It is difficult to know whether headache exists or not at the early age at 
which this disease commonly occurs. The convulsive movements gene- 
rally affect particularly the ej'es, and are followed by some degree of 
strabismus. The appetite is lost from the first ; the thirst is moderate ; 
there is no constipation. Soon after the symptoms just described, ap- 



SYMPTOMS. 481 

pear permanent contractions of the hands and feet, which are followed 
by attacks of tonic or clonic convulsions, during which sensibility and 
intelligence are abolished. Between the attacks of convulsions there is 
somnolence, which, though slight at first, becomes more marked as the 
case goes on. The attacks of convulsion become more and more frequent 
as the case progresses, until at last they are nearly constant. The tonic 
convulsions affect the limbs and trunk both, but particularly the former, 
whilst the clonic spasms occupy sometimes one side of the body, some- 
times the upper extremity alone, and at other times the whole body, but 
even then are usually stronger on one side than on the other. Paralysis 
is rarely noticed in the disease;, it occurred only in one out of nine cases 
observed by M. Legendre, and in one out of seventeen observed by MM. 
Killiet and Barthez. 

Dr. West remarks (p. 1061): "The absence of paralytic sjanptoms, 
however, is not the sole cause of the obscurity of these cases, but the in- 
dications of cerebral disturbance, by which they are attended, vary greatly 
in kind as in degree. The sudden occurrence of violent convulsions and 
their frequent return, alternating with spasmodic contraction of the fingers 
and toes in the intervals, appear to be the most frequent indications of 
the effusion of blood upon the surface of the brain. I need not say, how- 
ever, that such symptoms, taken alone, would by no means justify you in 
inferring that its effusion had taken place." Dr. West adverts particu- 
larly to the fact that apoplexy in the child is especially apt to occur in 
those who are weakly and feeble, and gives to this form of the disease 
the appellation of the cachectic form of cerebral hemorrhage. 

The chronic form presents most of the symptoms which exist in acquired 
chronic hydrocephalus from serous effusion into the ventricles. The cra- 
nium is very large in proportion to the face ; the sutures are not ossified; 
there is strabismus, with dilatation of the pupils ; the sense of sight is 
generally but not always retained ; the face loses its expression ; if the 
child was old enough at the moment of the attack to show signs of in- 
telligence, the latter are found to diminish rather than increase, and 
sometimes they are lost entirely, as the size of the head augments ; and 
the child is apt to utter loud cries, particularly during the night. The 
cutaneous sensibility is in general neither lost nor diminished. The power 
of motion usually remains, though it was entirely lost in one case. The 
appetite and thirst persist. 

The duration of cerebral apoplexy is very irregular. In one case quoted 
by MM. Rilliet and Barthez, it was a quarter of an hour ; in another an 
hour ; in a third forty-eight days ; and in one reported by M. Yalleix, in 
a very young infant, recovery was nearly perfect in a little less than two 
months, when the child was seized with pneumonia and died. 

The duration of meningeal apoplexy is also irregular. According to 
M. Legendre, all the recent cases seen by him in the Children's Hospital 
died in from eight to twelve days, apparently rather from intercurrent 
diseases than from the primary affection itself, whilst cases occurring in 
subjects placed in better hygienic conditions, and not attacked with in- 
tercurrent affections, passed into the second or hydrocephalic stage of 

31 



482 CEREBRAL HEMORRHAGE. 

the disease. The second stage lasted, according to the same author, in 
the four cases which he witnessed, from eight to thirtj' months, and 
then death was the result, not of cerebral symptoms, but of complications 
affecting the thoracic organs. 

Diagnosis. — The diagnosis of cerebral hemorrhage is, as we have 
already stated, very difficult, unless hemiplegia exist. When the case 
commences, as it often does, with convulsions or with inflammatory 
symptoms, it is often impossible to distinguish it from acute or tuber- 
cular disease of the brain. 

The diagnosis of meningeal hemorrhage is also very often extremely 
difficult. Not unfrequently it occurs in the course of other diseases, and 
is then entirely latent. In acute, primary cases, the most important and 
distinctive sj'mptoms are the early age of the subjects, between one and 
three years generally ; the violent fever from the commencement, marked 
by full, frequent, and regular pulse ; the absence of constipation ; the fre- 
quency of the convulsive attacks, and particularly the permanent con- 
traction with rigidity of the feet and hands. 

The diagnosis between the form of Irvdrocephalus which follows menin- 
geal apoplexy, and ventricular serous hydrocephalus, is exceedingly ob- 
scure. The only circumstance which seems to have any real value is age. 
MM. Rilliet and Barthez state that the} r have never known a child of two 
years old, or younger, to die of ventricular serous hydrocephalus from 
tumors, whether tubercular or not, of the brain ; in all such cases the effu- 
sion has been the result of a hemorrhage. 

Prognosis. — The prognosis of both forms of the disease is very grave. 
It is impossible, however, to ascertain the prognosis with an} 7 - certaint} T , 
so long as the symptomatolog}^ of the two affections is so obscure as we 
have found it to be. That cerebral hemorrhage is susceptible of cure, 
however, is proved by the case reported by M. Yalleix, already referred 
to, in which the child had nearly recovered, when it was seized with 
another disease which destro} T ed it. Kecovery from meningeal apoplexy 
is certainly extremely rare ; we believe, however, that we have met with 
one case in which this affection terminated favorably. 

Treatment. — The treatment must depend on the diagnosis and the 
special character of the sjmiptoms in each case. In a sudden and severe 
attack, occurring in a strong and hearty child, in which the S3~mptoms of 
congestion of the brain are strongly marked, and where we are not yet 
certain that actual hemorrhage has taken place, we should immediately 
resort to a general or local bloodletting. It was formerly customary to 
employ venesection in all such cases, but we believe that equal relief can 
be obtained by freely cupping or leeching the back of the neck. 

When, however, we have every reason to believe that blood has been 
effused either iu the membranes or into the substance of the brain, it is 
evident that bloodletting can produce but little effect, and that only in 
reducing the general fulness of the cerebral vessels. In such cases we 
should limit ourselves to the application of a few cut cups or leeches to 
the nucha. 

It must further be remarked, however, that in many cases of cerebral 



TREATMENT. 483 

or meningeal apoplexy, depletion in any form is entirely contraindicated ; 

since, as has already been stated, the effusion of blood occurs frequently 
in feeble and weakly children, and either in the course of some acute or 
chronic disease, or as a consequence of previous diseases which have ex- 
hausted the forces of the constitution and induced a state of dyscrasia 
and diffluence of the blood. In such cases as these we must depend upon 
the use of rest, cold applications, purgatives, and counter-irritants as 
recommended below. 

Cold applications should be immediately made to the head, either by 
wet cloths, the ice bladder, or by cold affusion. At the same time, or as 
early as possible after the invasion, a dose of some purgative medicine 
must be given. The best is calomel, either alone or combined with jalap 
or rhubarb. If given alone, it ought to be followed in an hour or two by 
castor oil, infusion of senna and manna, salts, magnesia, or some active 
cathartic. TVhen the sjmiptoms are very urgent, it is well to open the 
bowels still more speedily by a purgative enema. 

Counter-irritants are always useful adjuvants to the remedies already 
mentioned. They should consist at first of mustard plasters applied to 
the extremities, and shifted from place to place. When the s3^mptoms 
do not yield after proper depletion and the use of sinapisms for some 
hours, it is well to apply blisters to the calves of the legs, and to the nape 
of the neck. 

The diet must be very strict, and should consist only of barley or arrow- 
root water, for a few da} T s. 

The temperature of the room should be kept cool ; and the child should 
be placed with the head and trunk somewhat elevated, and kept pro- 
foundly quiet. 

For the paralysis which follows apoplexy in children, we believe that 
the most important, and indeed the only treatment necessary, is atten- 
tion to the general health of the patient, in order to give to nature time 
and opportunity to effect the absorption of the clot which has been thrown 
out into the substance of the brain, or into the cavity of the arachnoid 
membrane. This process may possibly however be aided and hastened by 
the prolonged administration of iodide of potassium. In cases of meningeal 
apoplexy, when the disease assumes the chronic form, occasioning the 
kind of hydrocephalus we have described, there is little more to be done 
than to attend to the general health of the child, and to endeavor to pro- 
mote absorption of the fluid by the internal administration of diuretics, 
and the preparations of iodine. It has been proposed also to get rid of 
the fluid by tapping, as has been done in congenital hydrocephalus, and 
it is indeed in cases of the form we are now considerino- when the fluid 
is entirely external to the brain, and where no malformation or organic 
disease of the brain exists, that this operation has been found most suc- 
cessful. (See treatment of chronic hydrocephalus.) 



484 CHRONIC HYDROCEPHALUS. 

AKTICLE V. 

CHRONIC HYDROCEPHALUS. 

This term is applied to an affection characterized by an excessive ac- 
cumulation of serous fluid, either within the ventricles of the brain or the 
sac of the arachnoid. 

The names internal and external have also been applied to it, in accord- 
ance with the position of the fluid : the former being given to those cases 
where the ventricles are the seat of the morbid collection, and the latter in- 
dicating that the fluid has accumulated in the cavity of the arachnoid and 
consequently surrounds the exterior of the brain. Chronic hydrocephalus 
may either be congenital or acquired, the latter variety presenting the 
most interest in a practical point of view, since congenital hydroceph- 
alus is usually associated with some malformation of the brain which ren- 
ders extra-uterine life almost impossible. 

In either form it is a rare disease in Philadelphia, so that but few 
opportunities are afforded for studying either its pathology or treatment. 

Morbid Appearances. — There are indeed few diseases in which it is of 
more importance to correctly establish the exact nature of the morbid 
process and the resulting lesion, since, as we shall see in a later part of 
this discussion, questions of the utmost practical value hinge upon the 
determination. 

Internal Hydrocephalus. — In this condition the amount of fluid is 
often very large, and varies from half a pint or a pint, 'to even as much as 
a gallon. Trousseau mentions a case where the fluid weighed 30 pounds, 
and Frank one in which it weighed 50 pounds. The formation of this 
accumulation being gradual, the cavities of the brain accommodate them- 
selves to it, the ventricles become distended, and the communications be- 
tween their cavities are all enlarged ; and occasionally the septum lucidum 
is perforated. This distension is usually most marked in the lateral ven- 
tricles. The hemispheres of the brain yield to the pressure of the increas- 
ing collection in the ventricles ; their convolutions are unfolded and flat- 
tened, so that the interval between them is only marked by a sinuous 
shallow groove, and the hemispheres are so thinned out as to form a layer 
not exceeding a few lines in thickness. It is not unusual, however, even 
when the distension of the brain has proceeded to this extreme degree, 
to be able to trace the cineritious and white laj^ers, preserving their normal 
relations. The consistence of the expanded brain substance varies in 
different cases ; usually, however, it remains normal, or is even increased, 
though in some cases it has been found so soft as to tear upon the slightest 
traction. The structures at the base of the brain present the same changes 
in consistence. 

One of the most important questions in this relation, as bearing upon 
the causation of the affection, concerns the condition of the lining mem- 
brane of the ventricles. 

The analogy of all other serous membranes would lead us to infer that in 



ANATOMICAL APPEARANCES. 485 

those cases where no mechanical obstruction to the circulation exists, such 
as a tubercular tumor pressing upon the sinuses of the brain, we should 
look for the cause of the serous accumulation in a morbid state of the 
lining membrane of the ventricles. This view is fully confirmed by the 
study of fatal cases of internal hydrocephalus, since in many cases this 
membrane is found much thickened, and either softened or roughened 
and granular. The granular condition of the membrane presents many 
degrees : in some cases it is merely a slight irregularity of the surface, 
while in others there is an unevenness as marked as that of shagreen, or 
even a formation of granules, which, at times, measure one-third of an inch 
in diameter, or even become distinctly pedunculated. 

Occasionally, a false membrane is found lining one or both ventricles, 
as the result of the chronic inflammation of the lining membrane of these 
cavities. 

Even when the symptoms of hydrocephalus have not appeared until 
some time after birth, the brain may be found to present positive evi- 
dences of congenital malformation, in the retarded development of some 
of the structures at its base. 

The veins of Galen and sinuses of the dura mater are usually found 
in a healthy state, with their calibres quite free ; a fact which is of impor- 
tance in considering the mode of production of internal hydrocephalus. 

In external hydrocephalus, the collection of fluid occurs in the sac of 
the arachnoid, or in a pseudo-cyst resulting from the transformation of a 
blood-clot, as described in our remarks on meningeal apoplexy : the 
brain is separated from the cranial vault and compressed against the 
base of the skull, as the lung is forced back against the spinal column by 
the fluid of lrvdrothorax. 

The superior cerebral veins, passing from the surface of the brain to 
the longitudinal sinus, traverse the fluid, and at times are so much 
stretched as to raise the surface of the brain into points. 

Excepting in cases, however, where the disease is congenital and coin- 
cident with some original malformation of the brain, there is no absolute 
diminution in the size of this organ. 

The character of the fluid varies considerably in different cases, and 
probably depends to a great extent upon the cause. 

In an analysis by Spengler of the fluid evacuated in a case of hydro- 
cephalus by puncture, the fluid was clear and colorless ; specific gravity 
1010, of acid reaction, and contained no albumen. It also contained 
chlorides and phosphates of soda and potassa, but no sulphates. It ap- 
pears, therefore, in such cases as this, that the fluid is not the result of 
inflammation, but rather due to a passive dropsy. It is, we believe, espe- 
cially in cases of external hydrocephalus, where the fluid results from the 
transformation of a sanguineous effusion, that it possesses these characters. 

On the other hand, the fluid frequently contains a large amount of or- 
ganic matter, and closely resembles the effusion in pleurisy or pericarditis. 
Thus, in a case reported by Battersb}^, which was tapped eight times, 
the fluid always contained va^ing, and sometimes very large, propor- 
tions of albumen. 



486 CHRONIC HYDROCEPHALUS. 

Causes of Internal Hydrocephalus. — The opinions of the highest au- 
thorities and most experienced observers still differ widely upon this 
important point. 

We have alluded to the fact that not unfrequently the brain is found 
to present evidences of congenital malformation, and this fact has led to 
the opinion that internal hydrocephalus is almost invariably the effect of 
arrested development of the brain. 

Rilliet and Barthez place the effusion in this affection in the class of 
passive dropsies, and express their belief that most frequently the cause 
of internal hydrocephalus is to be found in compression of the veins of 
Galen or ventricular veins, caused by the development of a tumor in the 
cranial cavitj^, and usually in the lobes of the cerebrum. 

The unfavorable influence which either of these views would have upon 
the prognosis and treatment of this disease, is of course evident. 

On the other hand, however, the opinion is advanced that the starting- 
point of internal hydrocephalus is, in fact, a morbid condition of the 
lining membrane of the ventricles. 

We have briefly described the appearances of this membrane which 
have now been observed in numerous well-authenticated cases of internal 
Irydrocephalus, and which plainly indicate the pre-existence of a chronic 
inflammation, so that we are led to believe that in a certain number of 
cases, at least, the effusion is due to a slow inflammatory action in the 
lining membrane of the ventricles. Those cases in which these appear- 
ances have been found associated with retarded development of the brain, 
nuvv be readily explained upon the supposition that the inflammation has 
been excited at a more or less advanced period of intra-uterine life, and 
that the resulting effusion has so compressed the structures at the base 
of the brain as to prevent their normal development. We may add that 
many eminent authorities, as Trousseau, now adhere to this view. 

In cases, however, where the effusion into the ventricles depends upon 
the development of a tumor in the cranial cavit} T , the growth will 
usually be found to occupy the cerebral lobes in such a manner as to 
compress the veins of Galen, which pass along the under surface of the 
corpus callosum, and are indeed the only true ventricular veins. 

The causes of external hydrocephalus are perhaps less obscure and 
uncertain than those of the internal form. 

In some cases, the effusion in the sac of the arachnoid is evidently due 
to a rupture of some portion of a brain distended by accumulation of 
fluid in the ventricles, and hence is merely a sequel of internal Iryclro- 
cephalus. 

According to the able investigations of Legendre, and Rilliet and Bar- 
thez, one of the most frequent causes of external lvvdrocephalus is hem- 
orrhage into the arachnoid space ; the effused blood undergoing changes 
which result in the presence of large quantities of clear fluid, as described 
at length in our remarks on meningeal apoplexy. We have alluded to 
the fact that in many cases of external hydrocephalus the diminution in 
size of the brain is comparative rather than real ; but there are instances 
where this form of the disease is found associated with malformation of 






SYMPTOMS. 487 

the brain, which appears as a small, misshapen mass, pressed against the 
anterior part of the base of the skull. In such cases, it appears as 
though the fluid were poured out to fill up the vacuum between the skull 
and atrophied brain. It is also possible that these conditions may be 
produced by the occurrence of hemorrhage into the arachnoid space dur- 
ing intra-uterine life, and before the brain had attained its normal devel- 
opment. 

Symptoms ; Physical Appearance. — The unusual size of the head is 
one of the most striking s}'mptoms of hydrocephalus. In many cases 
associated with atrophy or retarded development of the bones of the face 
and the rest of the bod}", this enlargement appears even more monstrous 
than it in reality is. The diameters of the cranium are, however, very 
much enlarged ; cases beino; on record in which at the age of a few weeks, 

O 7 © O 7 

the circumference of the head has been twenty-three inches, or even more. 

The increase in the size of the head is not however invariably the ear- 
liest sign of the disease, being frequently preceded by marked symptoms 
of nervous disturbance, or of impaired nutrition. 

The bones of the cranial vault which contribute to this enlargement 
are the frontal, the parietals, the occipital, and the squamous portions of 
the temporals. When the disease makes its appearance before the ossifi- 
cation of the sutures and fontanelles has been completed, the gradual in- 
crease of the fluid separates these bones more and more widely. The 
occipital bone thus is pushed backwards, the parietals outwards and back- 
wards, the frontal upwards and forwards. The increase in the size of the 
head is thus effected by the widening of the sagittal and coronal sutures, 
and by enlargement of the anterior fontanelle. 

The displacement of the frontal bone gives rise to a marked promi- 
nence of the forehead, which overhangs the diminutive features: while at 
the same time the pressure of the fluid depresses its orbital plate into an 
oblique position, contracts the orbital space, and gives rise to the charac- 
teristic appearance of the eye, the globe being prominent but directed 
downwards so as to be buried beneath the lower eyelid, which conceals 
almost the entire cornea. 

The membrane which covers in the enlarged sutures is often distended 
and prominent, or remains on the normal level. A distinct sense of 
fluctuation is readily obtained by palpating one of these spaces, and in 
some cases, principally in young infants, and where the collection is very 
large, the head is absolutely translucent. When life is prolonged, and 
the disease arrested, the ossification of the cranial vault is effected by the 
development of numerous supernumerary bones or ossa triquetra in the 
membranous spaces. These little bones are consequently found in the 
largest numbers in the coronal and sagittal sutures, where the deficiency 
is greatest and most wide. When, on the other hand, the disease does 
not begin until the sutures have united and the fontanelles ossified, it is 
rare for the head to attain any very large size. In a few cases, however, 
occurring in children of even nine years of age, the sutures have reopened 
under the continuous pressure, and the bones have been found separated 
as much as half an inch. 



488 CHRONIC HYDROCEPHALUS. 

More usually, however, in such eases, the pressure seems to expend 
itself in thinning the cranial bones, which become reduced to mere shells 
of light, fragile compact bone. Occasional^, so far from inducing thin- 
ning of the bones, actual hypertroplry occurs, and the bones of the cranial 
vault acquire an unusual thickness, and at the same time are dense and 
indurated. 

The early S3~mptoms of the disease vaiy much. When it is congenital, 
there are nearly alwa3~s evidences of cerebral disturbance either from the 
date of birth or appearing within a few daj r s. These s} T mptoms are occa- 
sional^ slight, consisting merefrin an unnatural expression, with oscilla- 
tion of the eyes or strabismus : or, on the other hand, there inay be at- 
tacks of convulsions frequently repeated. 

These s3'mptoms speedily- become associated with enlargement of the 
head and the characteristic alteration of plrysiognoiny. When the dis- 
ease is strictly acquired, the early symptoms are even more varied. In 
one set of cases they are those of hemorrhage into the arachnoid ; in an- 
other the evidences of inflammation of the serous lining of the ventricles, 
of more or less acute character, are present ; whilst in numerous cases the 
only s}ariptoms which precede the enlargement of the head are those of 
failing nutrition. 

Usually the aspect of children suffering with this affection is tranquil, 
or they may even present a certain unnatural gravity and apathy of ex- 
pression. 

Cerebral Symptoms. — At times the intelligence of the child, though 
perhaps poorly developed, remains intact, and there is no marked cerebral 
disturbance. 

In other cases, however, the advance of the disease is attended with a 
gradual failure of the intelligence, and impairment of the special senses, 
and especially of vision. 

In addition to the displacement of the globes of the eyes and altera- 
tions in the pupils already mentioned, the accumulation of fluid rapidly 
causes obstruction to the return of venous blood through the sinuses, so 
that even at an early stage, ophthalmoscopic examination shows marked 
changes in the fundus of the eyes. These consist in increase in the num- 
ber and size of the veins of the retina, with later serous infiltration or 
even atrophy of the optic papilla. 

The nervous s3 7 inptoms are at times much more marked; and there may 
be frequently recurring convulsive attacks, or, as West mentions having 
seen in several cases, spasmodic attacks of difficult breathing, with a 
crowing sound in inspiration (laryngismus stridulus). 

According to Rilliet and Barthez, the common sensibility of the sur- 
face is often impaired ; and there may be more or less complete paralysis, 
or contraction with rigidity of the extremities. 

It is, of course, difficult to estimate the amount of suffering experienced 
by the little patients ; ordinarily it does not appear great, and indeed in 
some cases it has seemed chiefly due to the opposition offered by the 
cranial walls to the distension of the head. 



DIAGNOSIS. 489 

In one case of MM. Rilliet and Barthez, the development of acute pain 
coincided with the ossification of the fontanelles. 

The general condition of children suffering with chronic hydrocephalus 
varies greatly. 

In some cases the} T preserve their appetite and digestion, and appear 
well-nourished and strong to a late period in the attack; but more fre- 
quently they present marked evidences of impairment of nutrition. 

The appetite may indeed remain, but the child loses both flesh and 
strength ; the bowels are irregular, usually constipated, but alternating 
with temporaiy attacks of diarrhoea. 

In the majority of cases, perhaps, these symptoms are not sufficiently 
pronounced to establish the character of the attack, until the increasing 
size of the head becomes manifest, and the child acquires the distinctive 
physiognomy of hydrocephalus. Even after marked enlargement of the 
head has occurred, however, the advance of the case is far from being 
uniform. In almost every instance there are pauses of the most variable 
frequency and duration, during which the child seems free from pain, im- 
proves in general condition, and the development of the head is tempo- 
rarily arrested. 

Death is frequently directly induced by some intercurrent affection, 
wholly unconnected with the disease of the brain ; while, in other cases, 
it immediately follows a violent attack of convulsions, or is preceded by 
symptoms of an acute exacerbation of the cerebral disorder. In some 
cases, also, the patients sink into a condition of atrophy, and die worn 
out b}* the protracted suffering and malnutrition. 

Diagnosis. — During the early stage of the disorder, if the nervous 
symptoms are slight, consisting merely in occasional attacks of heat of 
the head, attended with pulsation or tension of the anterior fontanelle, 
and restlessness and ciying, the diagnosis must remain uncertain. After 
the enlargement of the head has progressed to any considerable degree, 
the expression of the little patient, taken in conjunction with the other 
symptoms, is usually perfectly characteristic and conclusive. 

The morbid condition with which it is most likely to be confounded, is 
rickets of the skull. In fact, in some cases, the enlargement of the head, 
which results from these two affections, is quite identical. Usually, how- 
ever, this is not the case ; and the hj^pertrophy of the rachitic bones takes 
place irregularly, so that the skull acquires a square instead of a rounded 
form ; the orbital plates of the frontal bones are not displaced ; so that, 
although the forehead may be large and overhanging, the axes of the eyes 
are not disturbed ; the fontanelles are not widely open, prominent, or dis- 
tended ; and, finally, of course fluctuation on palpation is never present. 
In addition to this, the evidences of rickets in other portions of the body, 
and the peculiar symptoms of that affection, as detailed in the article de- 
voted to its consideration, nearly always enable the diagnosis to be 
readily made. 

We have already mentioned the changes which ophthalmoscopic ex- 
amination shows in the retina in this disease, and as similar examination 
reveals no lesion whatever in cases of rachitic enlargement of the head, 



490 CHROMIC HYDROCEPHALUS. 

it is evident that the use of the ophthalmoscope may be of material aid 
in establishing the diagnosis between these affections, which is, despite 
all the points of distinction above referred to, obscure and difficult in 
some few cases. 

In doubtful cases assistance may possibly also be derived from cerebral 
auscultation ; the presence of a bruit over the anterior fontanelle being 
thought by some authors to be a valuable indication of the rachitic nature 
of the enlargement of the skull. The significance of this cephalic bruit is, 
however, so much disputed, that it is at present impossible to assign an}^ 
definite value to it. 

The only other pathological condition with which chronic hydroceph- 
alus is apt to be confounded, is hypertrophy of the brain, an extremely 
rare affection, due to an increase of the interstitial connective tissue of 
the brain, the so-called neuroglia. 

In hypertrophy of the brain, how T ever, the symptoms do not usually 
appear so earl}' as in chronic hydrocephalus, nor is the cerebral disturb- 
ance so marked as in the latter affection. The enlargement of the head, 
also, which is the most characteristic feature of both conditions, is not 
so great in hypertroplry of the brain, and, instead of being uniform and 
assuming a rounded form as in hydrocephalus, occurs especially at the 
occiput. There is, farther, no depression of the orbital plates of the 
frontal bones in hypertrophy of the brain, so that the axes of the ej^es 
are not disturbed, and the globes are not displaced in the way we have 
already described as so characteristic of hydrocephalus. 

Finally, the sutures are not so widely open, nor the fontanelles tense 
and prominent as in hydrocephalus ; and, of course, the fluctuation which 
can be detected on palpation in some cases of this latter disease is never 
present. 

Prognosis. — Chronic hydrocephalus still ranks among the most fatal 
diseases ; so much so that Rilliet and Barthez — who, however, attribute 
its production usually to the presence of a tumor in the brain — express 
their belief that it is invariably fatal. Indeed, it must be borne in mind 
that in man}^ cases treatment must necessarily fail from the coexistence 
of some extensive congenital malformation of the brain. We should sus- 
pect the presence of this complication when there is serious disturbance 
of the nervous system, such as paralysis, or frequent and apparently 
causeless convulsions. Unfortunately, however, these hopeless cases can- 
not always be distinguished. 

The prognosis in cases of external hydrocephalus, especially when of 
acute origin, is less unfavorable than when the effusion takes place into 
the ventricles. 

Whatever be the seat of the effusion, however, and the size of the head, 
the case must not be regarded as hopeless and beyond reach of remedial 
measures so long as the functions of the brain are well performed, since 
there are well-authenticated cases of complete recovery from chronic hy- 
drocephalus, even when congenital. 

Treatment. — It must be sufficiently evident, from the previous con- 
sideration of this affection, that there are numerous cases in which all 



TREATMENT. 491 

treatment must prove unavailing, from the serious organic disease of the 
brain which accompanies it. Under any circumstances, however, the 
nature of the treatment and its efficiency will be much influenced by the 
early stage at which it is instituted. 

In regard to the utility of various special remedies, also, there is the 
greatest diversity of opinion ; and, indeed, there is no plan of treatment 
which possesses so much evidence in its favor as that origin ally proposed 
by Professor Golis, of Vienna. 

If the disease be in its incipience, and the constitution and hereditary 
tendencies of the child free from taint, this distinguished physician recom- 
mends that the head should be shaved, and one or two drachms of dilute 
mild mercurial ointment rubbed daily into its scalp. While this treat- 
ment is being carried out, the head should be constantly protected by a 
flannel cap. At the same time, calomel should be given in doses of one- 
sixth to one-fourth gr. twice daily, unless it irritate the bowels, when the 
inunction alone should be continued. 

If after pursuing this treatment, conjoined with the most careful atten- 
tion to diet and all hygienic precautions, for five or six weeks, there is 
marked improvement in the condition of the child, the mercurials may 
be gradually discontinued. 

The iodide of potassium has been highly recommended as a substitute 
for the mercurials above-mentioned, and several cases of apparent re- 
cover}- under its use are on record. It should be given in large doses, 
and for a considerable length of time. Trousseau, who recommends its 
use, joins to its internal administration the external application to the 
head of lotions containing iodine. 

Should the disease remain uninfluenced at the end of this time, it is 
proper to add to the treatment diuretics and counter-irritants, in the form 
of issues in the back of the neck, which may be kept open for several 
weeks. Dr. West recommends the frequent application of blisters as a 
substitute for the use of issues. 

During the emphypnent of this or any other mode of treatment, it will 
be occasionally necessarj^ to have recourse to antiphlogistic remedies, to 
subdue the exacerbations of heat and restlessness which occur more or 
less frequently, and threaten the development of an acute inflammatory 
condition. Nor should we fail to pay attention to the proper performance 
of all the functions ; to the maintenance of the appetite and digestion by 
the use of tonics ; and in case of the existence of a scrofulous diathesis, 
to the administration of cod-liver oil, iodide of iron, &c. 

When, despite the most careful employment of well-directed measures, 
the disease is clearly advancing, it is worse than useless to persist in any 
plan of treatment which annoys or absolutely pains the doomed child ; 
our only endeavor should then be to subdue any intercurrent disorder 
which might hasten the fatal result. 

More than twenty-five years ago, the use of compression of the head, 
to prevent its yielding to the accumulating fluid, was urged by Barnard, 
and experience has shown it to be a valuable adjunct to other treatment, 
though it is inapplicable while any acute symptoms are present, and 



492 CHRONIC HYDROCEPHALUS. 

according to West is best adapted to cases of external Irydrocephalus 
succeeding to hemorrhage into tbe arachnoid space. 

M. Trousseau recommends the following mode of applying this pres- 
sure : Strips of adhesive plaster, about one-third inch wide, are passed 
from each mastoid process to the outer part of the orbit of the opposite 
side ; from the nape of the neck along the longitudinal sinus to the root 
of the nose ; across the whole head, intersecting at the vertex ; and finally 
are kept securely in position by a strip passed thrice around the head, 
the ends of the previous strips being turned up over the first coil of this 
strip, and secured by the succeeding turns. 

It becomes necessary to loosen these strips instantly, if any symptoms 
of compression of the brain develop themselves, since the increasing 
pressure of the accumulating fluid may produce irreparable injury to the 
base of the brain, or even, as happened to M. Trousseau, detach the 
ethmoidal bone from its connections. 

The unfavorable results of all strictly medicinal treatment, impelled 
plrysicians, at an early date, to resort to active surgical interference in 
chronic Irydrocephalus, by puncturing the cranium and evacuating the 
fluid. 

The operation should be performed with a delicate trochar and canula, 
the puncture being made in the coronal suture, about an inch or an inch 
and a half from the longitudinal sinus, — and in a majority of cases, no 
evil consequences appear to follow the operation itself. Much difference 
of opinion still exists, however, as to its curative influence. From a rigid 
.analysis of 56 reported cases in which this operation had been performed, 
Dr. West came to the conclusion that in only 4 had a permanent cure 
"been effected. Other successful cases have been since reported, so that 
the operation must be recognized as at least a justifiable one. 

The circumstances favorable to its performance are, when the hjTlro- 
cephalus is external ; or when internal, is due to previous inflammation 
of the lining membrane of the ventricles ; when there is no reason to 
believe that the disease is congenital, and attended with arrested de- 
velopment of the brain ; when, though the head may be very large and 
increasing in size, the cerebral functions are not seriously impaired; and, 
finally, when the nutrition of the child is still good. 

Until, however, the treatment previously recommended has been faith- 
fully tried, and unless the disease be evidently advancing, a resort to 
this operation would be incurring grave risks with but slight prospect of 
success. 

Brainard, of Chicago, has recently recommended the injection of solu- 
tions of iodine into the cranial cavity, after puncture and evacuation of 
the fluid. He has employed this in at least two cases, without the develop- 
ment of an} T severe S}'mptoms as a direct consequence of the treatment. 

One of the cases died at the end of eight months ; the other at the date 
of the report, only thirty-five days after the operation, had shown no un- 
favorable symptoms. 

He advises the use of an aqueous solution of iodine, in proportion of one- 
third gr. with one gr. of iodide of potassium, to f Ji distilled water; of this 



ECLAMPSIA. 493 

from f 5i to fgi, may be injected; the strength of the solution and the 
amount injected being increased at subsequent punctures. 

In one of his cases, twent} T -one injections were practised in the course of 
seven months. 

Injections of this strength are usually followed by no sj^mptoms of in- 
flammation whatever ; and this exemption has led to the employment of 
much stronger solutions. 

Thus Dr. Tournesko, of Bucharest (quoted bj^Bouchut), injected f^iij 
tr. iodine in f$v distilled water, immediately after having drawn off by 
puncture f^xxiv of serum. The operation was followed by slight febrile 
excitement ; but at the expiration of fifteen days the child seemed in 
excellent health, the circumference of the head having diminished from 
56-t to 43 centimetres. 



ARTICLE VI. 

GENERAL CONVULSIONS, OR ECLAMPSIA. 

General Remarks. — The word convulsions is a generic term applied 
to different forms of spasmodic disease, very dissimilar from each other 
in many of their characters. 

Writers make different classifications of convulsions according to their 
peculiar notions in regard to the nature and causes of these disorders. 
The best division is, it seems to us, that adopted by most French writers, 
who arrange them by their supposed causes, making three classes, idio- 
pathic, protopathic or essential, sympathetic or deuteropathic, and symp- 
tomatic convulsions. The first two classes are unaccompanied by appre- 
ciable lesions of the nervous centres, while the third is called symptomatic, 
because it includes cases of convulsions which are the sign or symptom 
of an appreciable lesion of the cerebro-spinal axis, as for instance, those 
which occur in the course of meningitis, tubercular disease, hydrocephalus, 
apoplexy, &c. In idiopathic or essential convulsions, the cause of the 
attack acts directly upon the nervous centres, while in those to which 
the term sympathetic is applied, the cause lies in the influence or effect 
upon the brain or spinal marrow of disease of some other organ ; to the 
latter class belong the convulsions which occur in the course of pneumo- 
nia, bronchitis, the eruptive fevers, &c. 

We shall not pretend to give an accurate account of symptomatic con- 
vulsions in this article, as they have already been treated of under the 
head of the different organic diseases of the brain in the course of which 
they occur. We shall refer to them in the present article only so far as 
may be necessary to elucidate the pathology, diagnosis, prognosis, and 
treatment, of idiopathic and sympathetic convulsions. 

There is a form of eclampsia occurring in children, which we shall de- 
scribe separately, as it differs in many of its characters from ordinary 
convulsions. This is the disease known by the names of spasm of the 



494 ECLAMPSIA. 

glottis, thymic or Kopp's asthma, laryngismus stridulus, and eclampsia 
with suffocation. 

Definition ; Synonymes ; Frequency. — By the term convulsion is 
meant a paroxysm of variable duration, usually attended with uncon- 
sciousness, and followed by stupor, and characterized b} T a primaiy in- 
Yoluntaiy tonic contraction followed by irregular clonic spasms of the 
affected muscles. 

Iu general convulsions, to which the above definition especially ap- 
plies, the entire system of voluntary muscles is usually affected ; though 
as will be described hereafter, the attack may be a complete and genuine 
one of eclampsia, and yet the convulsive movements be limited in their 
extent to a single group of muscles, or even a single muscle. 

The only sjmonymes which it is necessaiy to mention are epilepsia 
puerilis : insultus epilepticus, and eclampsia. The latter term, eclampsia, 
is, we believe, preferable to any other, and we would gladly introduce it 
instead of convulsions, which is too general a term to express the form 
of disease under consideration. 

The frequency of eclampsia is very great. During the five years from 
1844 to 1848 inclusive, 1729 children under fifteen years of age died in 
this city of convulsions; whilst, during the same time, 1611 died of in- 
fantile cholera, 1060 of marasmus, 1041 of dropsy of the brain, and Y72 
of pneumonia, showing that eclampsia was the cause of a larger number 
of deaths than any other of the diseases just mentioned. It must be 
recollected, however, that a very large number of these cases ought, be- 
yond doubt, to have been returned under other titles, as man}' of them 
must have been a mere result of organic disease of the cerebro-spinal 
axis, and of other acute local or general diseases. 

Predisposing Causes. — Essential and sympathetic convulsions are 
much the most frequent before the age of seven years, which is the case 
also in regard to symptomatic convulsions, though the latter often occur 
after the age mentioned. Of 91 cases of convulsions that we have met 
with, in which the age was noted, 19 occurred in the first year, 26 in the 
second, 20 in the third and fourth, 23 between the fourth and ninth, and 
3 between the ninth and thirteenth years of life. Dr. West {op. cit., p. 
42) states that according to the Fifth and Eighth Reports of the Regis- 
trar-General, the deaths from diseases of the nervous sj'stem in the me- 
tropolis, under one year of age, bore a proportion of 30.5 per cent, to the 
deaths from all causes ; from the first to the third } 7 ear, the proportion 
was 18.5 per cent. ; from the third to the fifth year it was 1*7.6 per cent. ; 
from the fifth to the tenth year, it was 15.1 per cent. ; whilst from the 
tenth to the fifteenth year, it was only 10.6 per cent., and the total above 
fifteen years was but 10.4 per cent. Again, to show the very great in- 
fluence of age upon the predisposition to convulsions, Dr. West states 
that, within the first } T ear, the deaths from convulsions constituted 73.3 per 
cent, of the total mortalit}' from diseases of the nervous s} T stem ; between 
the first and third years, the proportional mortality from convulsions to 
the total mortality from affections of the nervous system, was 24.9 per 
cent.; between the third and fifth years, it was 17.8 per cent.; between 



causes. 495 

the fifth and tenth .years, it was 9.9 per cent. ; while between the tenth 
and fifteenth years, it had fallen to 2.4 per cent.; and above fifteen years, 
it was but 0.8 per cent. 

Dr. West ascribes the great frequency of convulsions in early life to the 
predominance of the spinal over the cerebral system, and to the imperfect 
development of the brain. 

It is generally stated that convulsions are more common in girls than 
boys. MM. Rilliet and Barthez found this to be the case in their private 
practice, whilst in the hospital, S}-mpathetic and symptomatic convulsions 
were most frequent in boj^s. According to our experience, they have 
been almost equally frequent in the two sexes, since of 92 cases that we 
have seen in which the sex was recorded, 47 occurred in boys and 45 in 
girls. 

It has been generally supposed that a delicate and nervous constitu- 
tion is a powerful predisposing cause to convulsive attacks. This has 
been denied, however, by several recent writers, whose observation is 
very careful and accurate. We are disposed to believe that it is not so 
much a feeble or delicate constitution that predisposes to convulsions, as 
it is one characterized by a highly susceptible, irritable, and nervous 
temperament, which often exists, in our opinion, in connection with a 
health}^ and vigorous physical organization. Of 96 children in whom we 
have seen convulsive attacks, these occurred more than once in 13. Of 
the 13, nine presented every appearance of strong and vigorous health, 
with the exception that when laboring under any kind of sickness, as 
dentition, indigestion, the fever accompanying simple angina, in two the 
invasion of measles, and in one that of erysipelas, they immediately be- 
came extremely restless and irritable, or heavy and drowsy, and at a very 
early. period, and sometimes with very little warning, were seized with 
convulsions. In one, a well-developed infant in its first year, the convul- 
sions occurred every month or six weeks, without any appreciable cause. 
Three of the 13 were delicate: one was puny and feeble until after the 
completion of the first dentition, when it grew strong and hearty ; one had 
had an apoplectic attack when an infant, which had caused partial loss 
of power of one side ; and the third was very weak at birth, then grew 
stronger, and died in its second year of hydrocephalus following scarlet 
fever. The number of convulsions varied in the different subjects. In 1 
there were five different attacks, in another four, in 4 there were three, 
and in 5, two. In two the attacks were very numerous, recurring fre- 
quently, and from very slight causes, or without any appreciable cause. 
They all recovered but two, and are still living. Of the 11 now living at 
various ages, all but one are free from anything like epilepsy, and that 
one, though liable during three years, to attacks of an epileptiform char- 
acter, became gradually less and less subject to the seizures, and has now 
been for several years perfectly well in all respects. 

We have another patient, a boy, whose case is not included amongst the 
above, now five years old, who has had ten different attacks of convulsions. 
These attacks were all produced hy some disturbance of his health. Seve- 
ral of them have occurred at the outset of a febrile reaction caused b}' a 



496 ECLAMPSIA. 

simple catarrh of the upper air-passages, — the convulsions ushering in the 
catarrh just as they sometimes do an attack of measles or scarlet fever. 
On other occasions, the seizure has evidently been the result of a febrile 
movement c aused by indigestion or gastric irritation. After having had 
nine different attacks, he remained free from them for a whole year, and 
then had the tenth at the very beginning of a catarrh of the larynx, fauces, 
and nasal passages. This child has never as yet exhibited ai^ symptom 
whatever of disease, either acute or chronic, of the cerebro-spinal axis, 
and as the convulsions have always been connected with a febrile move- 
ment, there is every reason to hope that they are not epileptic. Another 
patient, likewise not included amongst the above, a girl now five years 
old, has also had frequent attacks, but as they are of short duration, 
always coincident with the fever of catarrh, or digestive disorder, and on 
one occasion that of measles, and as between the seizures her health is 
excellent, there is but little reason to fear epilepsy. 

It is generally believed that the predisposition to convulsions is some- 
times hereditary. We have remarked in regard to this point, that several 
children in the same family sometimes suffer from the disease, and that 
the nervous temperament to which we alluded above, appeared in some 
instances to have been inherited by the child from its parents. 

In one family that we attend, out of six children, all but one have 
had attacks of convulsions : one of these children had but one attack, and 
that was at the age of ten 3 T ears, and was caused by a fit of indigestion 
occurring during convalescence from pneumonia. The other four children 
had each several attacks, occasioned always by the febrile movement re- 
sulting from some of the numerous disorders of infancy. In none of these 
has there been any reason to suppose that the attacks were settling into 
epilepsy. 

Some very interesting evidence confirmatory of this view has recently 
been furnished by Dr. Robert P. Harris, of this city, in an article read 
before the Philadelphia Obstetrical Societ}^ (see Amer. Jour, of Obstet., 
vol. ii, No. 2, August, 1869). 

His record embraces 38 cases of eclampsia, 3*7 of which occurred in 13 
families, in which, collectively, there were 55 children who lived long 
enough after birth to prove their liability or exemption ; 4 having died 
too early to determine whether they were subject to convulsions or not. 

All of the individuals included in the statistics were descendants of 
the first, second, or third generations, of two pairs of ancestors ; of the 
present rising generation (the second) there are 31 members, only one 
of whom has as yet married; twenty of the 31 have had convulsions. 

The exciting causes of convulsions are exceedingly numerous and dis- 
similar. Amongst the causes of essential convulsions are cited vivid 
moral emotions, violent pain, high temperature, exposure with the head 
uncovered to the sun, and sudden exposure to cold. In many cases, 
however, the exciting cause cannot be detected. The exciting causes of 
S3^mpathetic convulsions may be almost any of the diseases incident to 
childhood. Amongst them we will cite as the most frequent, hooping- 



SYMPTOMS. 497 

cough, pneumonia, catarrh, scarlatina, measles, violent fever from any 
cause, dentition, and indigestion. 

Of 96 cases of convulsions, of which we have preserved notes, we have 
regarded only 4 as essential, while 70 were sympathetic, and 22 symp- 
tomatic. Of the 4 essential cases, we could not detect the exciting cause 
in any. Of the TO sympathetic cases, it was scarlet fever in 12 ; pertussis 
in 9 ; indigestion in 13 ; pneumonia in 3 ; the fever of simple angina in 6 ; 
cholera infantum and bronchitis, each 3 ; dysentery, 4 ; measles and den- 
tition, each 6 ; enteritis, the fever and irritation caused by a burn upon 
the back, and the onset of eiysipelas, each 1 ; an overdose of castor-oil 
(5vi) given to a young child with a slight cholera, 1 ; and lastly, fecal 
accumulations in the large intestine, 1. 

Symptoms. — Pi*odromic Symptoms. — It has been asserted b}^ some 
writers that most attacks of convulsions in children are preceded by pro- 
dromic symptoms, which indicate to the experienced eye their approach. 
This does not agree exactly with our own experience, at least in regard 
to the essential and sympathetic forms, since of the cases of the former 
variety, well-marked prodromes did not occur in any, aild of 64 cases of 
the latter, in which the early sjmiptoms were noted, strongly-marked pre- 
cursory phenomena occurred only in 8. We do not mean to say that 
there were no s3 T mptoms in the other 56 cases, which might have indicated 
to an experienced eye the probability of an approaching attack of convul- 
sions, but merely that there were none that were strikingly characteristic, 
none which pointed out clearly and decisively that such a crisis was 
close at hand. In many of the 56, there were symptoms that might be 
regarded as indicating, with various degrees of probability, the approach 
of the convulsive seizure ; but, inasmuch as they were such as constantly 
exist in children not predisposed by temperament or constitution to 
eclampsia, without the development of the disease, they scarcely deserve 
to be called precursory symptoms. 

The precursory sjmaptoms of idiopathic and sympathetic convulsions 
are, therefore, difficult to describe because of their variable and uncertain 
character. They consist in general, however, of whatever indicates a 
highly disordered condition of the nervous system. The most marked 
symptoms are unusual drowsiness, excessive irritability, a peculiar physi- 
ognomical expression, general tremors, and the drawing of the thumbs 
into the palms of the hands, or rigid flexion of the toes. The drowsiness 
which precedes an attack of eclampsia, is almost always accompanied with 
some restlessness. The sleep is light and easily disturbed ; the child 
moves and turns, or starts and moans ; often it seems to have frightful 
dreams, and will scream out or wake suddenly bewildered and terrified, 
and when roused is generally exceedingly irritable, cr}ung violently or 
fretting at the slightest contrariety, or without cause. The face, and par- 
ticularly the eyes, often exhibit a peculiar expression altogether different 
from their usual appearance. The expression which has most struck us 
and which we have seen on several occasions, is a fixed and staring look, 
lasting but for an instant, as though .the child were looking intently at 
some object, while in fact it is gazing at vacancy; at the same time the 

32 



498 ECLAMPSIA. 

expression is entirely without meaning. The child seems in fact, for a 
moment, to be in a state of ecstasy. In some instances a sardonic smile 
is seen to pass over the countenance just before the attack. The tremors 
or tremblings alluded to above, occur both in the sleeping and waking 
state, but particularly in the former. Flexion of the thumbs and toes 
has been noticed by different observers, but is, we believe, a sign rather 
of the approach of symptomatic, than of essential or sympathetic con- 
vulsions. 

The precurscny sj'mptoms of sj'mptomatic convulsions will depend on 
the nature of the disease in the course of which they occur. Not unfre- 
quently the convulsions occur at the very outset of the disease of the 
brain or spinal marrow, when of course there will be no prodromic symp- 
toms whatever. According to Dr. Marshall Hall (Diseases of the Nervous 
System, p. 149), the first and most frequent sign showing that the excito- 
niotor} r system is becoming complicated in diseases of the brain is vomit- 
in o-, after which come strabismus, a contracted state of the muscles of the 
thumbs or fingers, or some unequivocal spasmodic or convulsive affection 
of the respiratory muscles, or of the muscles of the limbs. 

Symptoms of the Attack. — With or without the precursory symptoms 
just described, the convulsion itself usually begins suddenly. The child 
often utters a cry ; loses consciousness and is seized with powerful tonic 
contraction of the voluntary muscles ; the e} r es are for a moment fixed 
and staring, and then drawn obliquely upward under the upper lid, so that 
the white portions of the balls alone are visible for an instant between 
the partially open lids ; the trunk is rigid and stiff, the thorax immovable, 
the respiration suspended by rigid spasm of the respiratory muscles ; the 
face, for a moment pale, usually becomes livid and congested, and the 
veins of the neck are distended. 

This state of tonic spasm is followed quickly b} 7 the stage of clonic 
spasm, in which involuntary and most irregular convulsive movements 
occur. The eyes are rarely fixed in one position, but are constantly agi- 
tated in various directions, from side to side, or upwards and downwards ; 
very often there is the most Adolent strabismus ; the eyelids are sometimes 
open, at others shut ; the pupils ma} T be contracted or dilated. The mus- 
cles of the face next enter into contraction, and occasion the most hideous 
contortions of the features. The mouth is distorted into various shapes, 
the lips are often covered with a whitish or sanguinolent froth, and the 
jaws tightly clinched together by tonic spasms, or agitated by convulsive 
movements, so as to produce grinding of the teeth. The trunk of the 
body is also sometimes variously contorted by clonic convulsions. The 
head is usually strongly retracted upon the trunk, but in other instances 
is drawn to one side, or violently rotated. The muscles about the front 
of the neck enter into action, and alternately elevate and depress the 
lar}nax ; the tongue, when it can be seen, is observed to be moved in dif- 
ferent directions, and is sometimes caught between the teeth and severely 
bitten. The extremities, particularly the superior, are more violently con- 
vulsed than any other parts. The fingers are drawn into the palms of the 
hands, the forearms are flexed and extended upon the arms by short, 



SYMPTOMS. 499 

rapid, and generally rhythmical movements, the hand is quickly pronated 
and stipulated upon the arm, or finally the whole upper extremity is 
twisted and distorted into various positions, which it is impossible to de- 
scribe. The inferior extremities undergo similar movements, but almost 
always in a less degree than the upper. The respiration during the at- 
tack is irregular, sometimes suspended by rigid spasm of the respiratory 
muscles, and sometimes accelerated. A spasmodic contraction of the 
larynx, producing noisy inspirations, has been noticed by several writers. 
We shall find when we come to consider the nature of this disease, that 
Dr. Hall is of opinion that a more or less complete closure of the larynx 
is the most important feature of the convulsive crisis. The face is often 
livid and deeply congested, especially when the respiration is embar- 
rassed ; the head is hot, whilst the extremities are cold ; the pulse be- 
comes large and full, or frequent and small, and sometimes cannot be 
counted in consequence of the contractions of the muscles of the forearm. 
The face is not alwa} T s however congested. We have sometimes seen it 
perfectly white, while the convulsions were severe, and the child pro- 
foundly insensible. The action of the heart is tumultuous, and some- 
times irregular or intermittent. When the attack is very violent, the 
urine and fseces are occasionally discharged inA T oluntarily, but these are 
rare symptoms. Deglutition is seldom impossible even in the severest 
fit. In severe, and especially in long-continued attacks, intellectual con- 
sciousness, and general and special sensibility, are all abolished. In 
milder cases, though consciousness is destro3 T ed, some of the special 
senses still respond to irritants, whilst in still slighter cases, the intelli- 
gence also is more or less preserved. 

As the termination of the attack approaches, the convulsive movements 
become more and more feeble, until they finally cease entirely, and the 
child falls into a state of deep sleep, or of more or less profound stupor. 

Convulsions are not alwa3 T s, as we have just described them, general. 
They may be circumscribed or partial, affecting one side of the body 
more than the other, or one side alone, or a single arm, or in some cases, 
indeed, only a single muscle, as the biceps. Sometimes they implicate the 
ej'es onty. The inferior extremities are rarely affected alone. Of the par- 
tial convulsions the most frequent are those in which some parts of the 
face and upper extremities are attacked. In this form of the disease, the 
disorders of the circulation and respiration, the congested tint of the face, 
the froth upon the lips, and the derangements of intelligence and sensi- 
bility, are much less strongly marked than in general attacks. 

In still other cases, which have been by various authors grouped to- 
gether under the objectionable title of " inward convulsions," the spasm 
affects chiefly the muscles of respiration ; at times being limited to the 
muscles of the larynx, and constituting the affection we shall describe in 
a special article under the name of laryngismus stridulus ; at others affect- 
ing principally the diaphragm and the thoracic and abdominal muscles of 
respiration. 

The duration of an attack of eclampsia concerns both the length of the 
convulsive crisis and the continuance of the disposition to renewals of 



500 ECLAMPSIA. 

the crisis. Both of these are Yery uncertain. We have known the attack 
to last in all its violence eight hours and a half in one case, and twelve 
in another, and it is said to have lasted much longer in some instances. 
"When the spasmodic movements continue during a long period, they are 
almost always interrupted by remissions. As a general rule, the dura- 
tion is much shorter than the periods above mentioned, — from a few 
minutes to half an hour. When the attacks cease and recur, as they 
often do, several times a day, they leave the patient during the intervals 
in a state of more or less perfect consciousness or somnolence, restless- 
ness or delirium, or finally of coma. The period during which the dis- 
position to recurrence continues, depends principally upon the cause of 
the convulsions. If this continue in action, they will be apt to return 
until it is removed. 

Idiopathic and S3mipathetic convulsions generally consist of a single 
attack, though there are sometimes several, which occur at intervals of 
some hours, or of one or two da} T s. Sympathetic convulsions usually 
occur either at the beginning or termination of the disease which they 
complicate, and much less frequently during its middle period. Of 46 
cases of this form observed by ourselves, complicating measles, scarlet 
fever, eiysipelas, pneumonia, bronchitis, cholera infantum, simple angina, 
and dysentery, in which the period was carefulry ascertained, they oc- 
curred at the invasion alone in 25, at the termination alone in 15, at the 
middle period alone in 3, and at the invasion and termination both in 3. 
It is curious to remark, that of the 25 cases that occurred only at the in- 
vasion of the disease, all but 7 recovered; that the 3 occurring in the 
middle period alone, also recovered ; that of the 3 occurring both at the 
invasion and termination, 2 died; and that all of those which occurred at 
the termination alone, proved fatal. 

MM. Rilliet and Barthez state that half the cases of symptomatic con- 
vulsions observed by them, occurred at the commencement of the ence- 
phalic disease. This form seldom consists of a single crisis ; the attacks, 
on the contrary, are repeated from time to time. The authors just quoted 
state that whenever the convulsive attacks have recurred repeatedly within 
a period of a few days, they have proved symptomatic of disease of the 
brain. 

Nature of the Disease. — One of the most important contributions 
which has been made towards a plausible and satisfactoiy explanation of 
the pathology of convulsions in children, was afforded us in the writings 
of Dr. Marshall Hall ; and, although more advanced knowledge of the 
physiology of the nervous system has shown that the part of the cerebro- 
spinal axis involved in the production of convulsions is not limited, as 
he supposed, to the true spinal system, his theory of excito-motor action 
furnishes the most read} T explanation of very many cases of eclampsia. 
Dr. Hall sa} T s (Diseases and Derangements of the Nervous System, p. 145) : 
" That the whole class of convulsive diseases consists of affections of the 
true spinal system, there is no longer any doubt. But these diseases do 
not all originate in this system." All convulsive disorders are, according 
to this doctrine, affections of the true spinal or excito-motoiy system. 



NATURE OF THE DISEASE. 501 

The causes of these disorders may be of incident origin, acting upon 
excitor nerves; of centric origin, seated in the brain or spinal marrow; 
or of reflex origin, acting upon reflex or motor nerves. They are called, 
therefore, according to their causes, central or centric, when they de- 
pend on disease of the nervous centres ; centripetal when they are excited 
through excitor nerves ; and centrifugal when they depend on disease of 
the motor nerves. 

Dr. Hall as is well known ascribed great importance to the condition 
of the glottis in convulsions. He says (p. 328), in speaking of epilepsy, 
" The second symptom is a forcible closure of the larynx and expiratory 
efforts, which suffuse the countenance and probably congest the brain 
with venous blood." At page 327, he says: U A spasmodic affection of 
the larynx has obviously much to do in this disease (epilepsy), as well as 
in the crowing inspiration or croup-like convulsion of infants ; so much, 
indeed, that I doubt whether convulsion would occur without closure 
of this organ." In describing the croup-like convulsion or laryngismus 
stridulus (p. 180), he says : "I must repeat the observation that the res- 
piration is actually arrested by the closure of the larynx; and there are 
forcible expiratory efforts only or principally in the actual convulsion." 
In a later publication, Dr. Hall says: " Without closure of the larynx, 
extreme laryngismus, and the consequent congestion of the nervous cen- 
tres, there could I believe be no convulsion ! This closure of the larynx 
must be complete in the affection under consideration (laryngismus strid- 
ulus), as in all others, before convulsions can take place." (Braith. Bet. 
from Lancet, June 12, 1841, p. 609.) 

It is, however, evident that the obstruction to respiration exists not 
only in the laiynx, but in the thorax, the muscles of which are rigidly 
contracted. Nor can we at present admit that this spasm of the muscles 
of respiration is more than coincident with the other phenomena of the 
convulsive attack ; and indeed there are reasons for believing that the 
accumulation of venous blood in the nervous centres which follows the 
obstruction of respiration, so far from causing the convulsion, has a ten- 
dency to arrest it, and to induce a state of coma. 

It is, however, easy to comprehend the mode of production of sympa- 
thetic convulsions by reference to these doctrines. They evidently de- 
pend upon morbid impressions conveyed to the cerebro-spinal axis through 
the excitor nerves having their origin in the diseased organs, probably 
conjoined with a state of undue reflex excitability of certain parts of the 
nervous centres. Thus it is easy to understand why inflammation of the 
parenchyma of the lung in pneumonia, of the bronchial mucous mem- 
brane in bronchitis, of the mucous membrane of the bowel in entero- 
colitis or dysentery, or the pharynx in angina ; why the pressure of a 
tooth upon an inflamed gum during dentition, the presence of a foreign 
body, as newspaper (in one of our own cases), or crude food, in the 
stomach, or fecal, or lienteric accumulations in the intestine, should pro- 
duce a degree of irritation in excitor nerves, sufficient, when transmitted 
to the sensori-motor ganglia, to occasion the convulsions we have been 
considering. 



502 ECLAMPSIA. 

It is more difficult to explain the mode in which continued fevers, mea- 
sles, scarlatina, &c, give rise to convulsions. To us, however, their oc- 
currence is explicable by the morbid effect produced upon the nervous 
centres by the blood, which is known to be more or less changed in these 
affections from its healthful condition, and also bj^ the mere fact of the 
existence of fever; for we have met with a number of children in our 
own practice, who are almost certain to have a convulsive seizure, when- 
ever the circulation becomes greatly excited in force and frequency by 
the existence of fever, no matter what be the cause of the fever. 

The explanation of the production of idiopathic or essential convul- 
sions is not always so easy, because we are sometimes unable to detect 
smy cause, either centric, centripetal, or centrifugal, to account for the 
excitation of the nervous system. It seems probable, however, that they 
must depend, like those of the sjnnpathetic form, upon some unhealthful, 
and therefore irritating condition, acting upon the excito-motory system 
of nerves. The cause may be so slight as to escape the notice of the 
physician, and } r et sufficient to produce a convulsive crisis in a child pre- 
disposed to eclampsia. It may be an unnoticed dentition, some undi- 
gested food in contact with the stomach or intestines, or accumulations 
of unhealtlrv fecal substances, or of vitiated secretions, in the intestines. 
When convulsions have followed a vivid mental emotion, as passion or 
vexation, they are evidently a result of the influence of that condition 
upon the nervous centres. Acute pain, which is said to have occasioned 
essential eclampsia, as well as exposure to violent heat or severe cold, 
must produce their effects through their action upon incident excitor 
nerves. There is also in all probability, in most children who suffer with 
convulsion, a state of preternatural mobility and increased reflex excita- 
bility of certain parts of the cerebro-spinal axis, which predisposes to 
disorderly nervous action, even upon trifling causes. There can be no 
doubt that this irritability of the nervous system is frequently inherited, 
though it ma}^ be acquired in the course of chronic debilitating diseases. 
Although we have described these convulsions under the title o# essential 
and sympathetic, we do not mean to assert that the3 r are absolutely inde- 
pendent of any material changes in the nervous centres, but merely that, 
up to the present time, no appreciable lesions have been detected as their 
causes. It is indeed true, that, in a certain number of instances, after 
death from eclampsia, there are found engorgement of the vessels of the 
membranes and of the substance of the brain, serous effusion into the 
cavity of the arachnoid or the lateral ventricles, or even actual cerebral 
hemorrhage. But these lesions cannot be considered as the causes of the 
convulsive attack, but on the other hand must be regarded as the direct 
result of the convulsion, and due to the intense vascular engorgement 
caused by the spasm of the respiratory muscles and the consequent arrest 
of the venous circulation. And indeed it is the danger of the occurrence 
of such lesions which imparts much of the gravity to the prognosis in 
all severe attacks of eclampsia in young children. 

All symptomatic convulsions belong, of course, to the class of centric 
diseases. These need no further remarks. 



DIAGNOSIS. 503 

Diagnosis. — There are two important points to be considered in treat- 
ing of the diagnosis of eclampsia: the diseases with which it may be 
confounded, and the causes which may have produced the convulsions, 
or, in other words, their distinction into essential, sj^mpathetic, and 
symptomatic. 

The only disease with which eclampsia is likely to be confounded, is 
epilepsy ; the mistake could only be made when the former is violent, and 
when it is accompanied and followed by unconsciousness. In epilepsy, 
however, the invasion is more sudden, the convulsions are accompanied 
with greater rigidity, there is alwa} T s frothing at the mouth, the duration 
of the crisis is shorter, and it is generally followed by more marked stupor. 
If the couvulsive attack have occurred under the influence of an appre- 
ciable cause, if the parents are not epileptic, and if the child is very im- 
pressionable, it is probably eclampsia. Again, the younger the patient, 
the more likely is the case to be one of eclampsia ; whilst if the child is ap- 
proaching towards pubertj^, if the attacks are frequently repeated, and yet 
not dependent on fever, and if the}^ are followed by complete restorations 
to health in the interval, the disease is much more likely to be epilepsy. 

The diagnosis of the form of the attack, whether idiopathic, sympathetic, 
or symptomatic, is exceedingly important, as upon this mast depend in 
great measure the prognosis and treatment. It is often very difficult, and 
sometimes impossible, to determine at the moment to which class the 
convulsions belong. The most difficult points in the diagnosis are the 
following: first, when a child previously in good health, is suddenly 
seized with the disease, to determine whether it is essential; whether it 
is s} T mpathetic and occasioned by disease which, up to this instant, has 
been latent, or by the invasion of some one of the acute local diseases, or of 
one of the continued fevers ; or lastly, whether it is symptomatic, marking 
the invasion of a disease of the cerebro-spinal axis : second, when the 
convulsion occurs in the course of a disease not implicating the nervous 
centres, to determine whether it is merely sympathetic of that disease, or 
whether it is symptomatic of an intercurrent affection of the brain or 
spinal marrow. 

It is impossible, for want of space, to treat of all these points in detail. 
The enumeration of them, however, will be useful in calling the attention 
of the reader to their importance. 

An essential convulsion is only to be distinguished by careful study of 
the antecedent history and present condition of the patient. If, after a 
thorough examination of all the organs, no diseased point can be detected, 
and if the child recover perfectly from the convulsion, we must conclude 
that the case has been an idiopathic one, in which the cause is beyond our 
reach. We are disposed to believe, however, as has already been stated, 
that in most such cases there has been a source of irritation in some of 
the organs of the bod}^, which has acted as the excitant to the excito- 
motory system, and which, if we could but detect it, would warrant us 
in classing the case amongst sympathetic convulsions ; and on this ac- 
count a searching physical examination should be made in every case, as 
a matter of course. 



504 ECLAMPSIA. 

The sympathetic and symptomatic forms of eclampsia are to be diag- 
nosticated by the same careful attention to the antecedent history and 
present condition of the child. If the latter is teething at the time of 
the fit, and there is no other cause to explain the attack, and should there 
be nothing in the consecutive symptoms to render such an explanation 
inadmissible, we may refer it to that condition. We may remark merely, 
that, as a general rule, eclampsia depending entirely upon the irritation 
of dentition, is seldom either violent or long-continued, and that the 
return to consciousness and health is speedy. The probable dependence 
of the attack upon indigestion is to be ascertained by the absence of other 
causes, and b} 7 our learning upon inquiry that the child had eaten of some 
indigestible substance within a few hours or a clay or two before the attack. 
Its dependence on intestinal accumulations is to be arrived at by the same 
negative or exclusive method, and bj 7 learning that the patient is usually, 
or has been of late, of a constipated habit. 

When the attack occurs in the course of some other disease, as pneu- 
monia, catarrh, enteritis, pertussis, scarlatina, or measles, it is almost 
certainly S3 T mpathetic. It ma} 7 possibly, however, be indicative of an in- 
tercurrent attack of cerebral disease. This can be determined only by 
attention to the consecutive phenomena. If the attack be short, and soon 
followed by complete restoration to consciousness, it is in all probabilit} 7 
sj'mpathetic. If, on the contrary, the convulsive crisis be long and se- 
vere, if the recovery from it be slow and imperfect, if it be followed by 
violent agitation, somnolence, or coma, or by some persistent lesion of 
motility, there is every reason to fear an attack of disease of the brain. 

Sympathetic convulsions, occurring at the invasion of different local or 
general diseases, are to be distinguished only by observation of the sj^mp- 
toms that follow the crisis, which will be those belonging to the particular 
malady whose approach has caused the attack of eclampsia. 

Symptomatic eclampsia is characterized b} T various signs of encephalic 
disorder, which soon follow the convulsive attack. The most important 
of these are severe and continued headache ; diminution or exaltation of 
general or special sensibility ; dilatation or contraction of the pupils ; 
irregular movements of the e3'es ; flexion or stiffness of some of the limbs, 
or of the fingers or thumbs ; disordered intelligence ; or the symptoms 
which have already been described in the articles upon the diseases of 
the brain. 

Prognosis. — The prognosis of essential convulsions must depend on 
the nature of the cause and the violence of the attack. When the cause 
has been slight, or one which soon ceases to act, or can be readily re- 
moved, the prognosis is much more favorable than under opposite con- 
ditions. If the convulsive crisis is short and of moderate severity, if the 
pulse and respiration are but slightly disturbed, if there be but little con- 
gestion of the face, ai\d no stertor, there is every reason to hope a suc- 
cessful issue in the case. Of the three cases of this class that we have 
seen, two recovered and one died. 

Sympathetic is more dangerous than essential eclampsia, but much less 
so than symptomatic. The prognosis will depend chiefly on the nature 



TREATMENT. 505 

of the disease which it complicates, and on the stage of that disease at 
which it occurs. Thus, in scarlatina, convulsions, especially when they 
occur in the first few days of the disease, are almost alwa} T s fatal, in 
measles much less so, and in other diseases in various proportions. They 
are very apt to terminate unfavorably when they occur after the malady 
which they complicate has been in progress for several days. This is a 
remark made by various authors, and we have already stated that of 46 
eases of this form in which we carefully ascertained the period of their 
occurrence, 25 appeared at the invasion, of which all but 7 ended favor- 
ably : 3 at the middle period, which all recovered ; 3 both at the invasion 
and at a later period, 2 of which were fatal; and 15 after the cases had 
been progressing for a considerable time, all of which proved fatal. In 
addition to these important elements for making the prognosis, we must 
consider, also, the duration and degree of violence of the paroxysm, the 
state of the patient after the fit as to its cerebro-spinal functions, and 
lastly the age and constitution of the child. 

The prognosis of symptomatic convulsions must depend very much 
upon that of the disease of which they are the s} 7 mptom. It may be 
stated, as a general rule, that, like those of the sympathetic class, they 
are less dangerous when they occur at the beginning than at a later period 
of the disease. They are always, however, very dangerous. Of 22 cases 
that we have seen, 19 were fatal. 

It frequently happens, however, that although life is not destroyed by 
the convulsions, certain grave sequelae remain, among which the most 
frequent are paralysis, disorders of the mind, and defects of speech or 
vision. These symptoms are, it is true, far most frequent in cases of 
s} T mptomatic convulsions, where they depend upon the same lesion of the 
brain which occasioned the fit. They may, however, succeed convulsions 
which we are still obliged to call essential, although there very possibly 
is some minute alteration or defect in a part of the nervous centres, which 
our means of observation do not suffice to detect. In such cases these 
sequelae probably depend upon some lesion of the brain, such as cerebral 
hemorrhage, which has occurred as a result of the convulsion. 

Hemiplegia, which is the form of paralysis which most frequently fol- 
lows eclampsia, is most apt to occur when the fit has been limited to one 
side of the body; it is often temporary, and passes away in a few days, 
though it may remain persistently. Dr. J. Hughlings Jackson suggests 
that, in the absence of evident disease in such cases of unilateral convul- 
sion and palsy in children, the symptoms may depend upon the plugging 
of very small vessels in the brain. 

Treatment. — We shall confine our remarks upon the treatment of 
eclampsia to the essential and sympathetic forms of the disease, having 
already treated of that of the S} 7 mptomatic form in the articles upon the 
cerebral diseases which give rise to it. 

We think that the treatment of eclampsia in children may be simplified 
if we pay attention to two distinct conditions of disorder, which appear 
to exist in every case. These are the condition of morbid irritation or 
derangement of the excito-inotory sj-stem of nerves, and the cause which 



506 ECLAMPSIA. 

occasions that derangement. The condition of irritation or disease of the 
cerebro-spinal axis exists in all cases, and is always the same, differing 
only in degree and extent ; whilst the morbid cause of that irritation dif- 
fers in each case, being in one dentition, in another pain, in another con- 
stipation, in others pneumonia or indigestion, pleurisy, catarrh, or angina, 
scarlet fever, measles, fright, or other violent emotions. If this view of 
the subject be correct, it is clear that in treating a case of convulsions we 
have to attend to the two morbid conditions referred to, and we shall be 
careful, therefore, in the course of our remarks, to treat of the remedies 
most proper for the removal of the cause, whatever it may be, which acts 
as the irritant to the nervous centres ; and of those calculated to subdue 
or allay- the deranged condition of those centres and the effects of that 
derangement. 

There are some general rules to be followed in the treatment of con- 
vulsions which apply to all cases, and of these we shall first speak. They 
are, to place the child in a large well-ventilated room, if such can be pro- 
cured ; if it have been seized in a little close room, where the atmosphere 
is dense and impure, removal to another room, or exposure to fresh air 
before an open window, has sometimes sufficed to terminate the crisis. 
At the same time the clothes of the child should be loosened, in order to 
prevent all constriction, and if necessary taken off, to allow of a careful 
examination of the whole body. We believe it is a good rule always to 
place the child, no matter what be the cause of the convulsion, if it be a 
severe one, in a icarm-bath (96° or 97° F.). This has frequently proved 
an efficient remedy, according to our experience. It is easily procured 
in most cases, and we are quite confident that we have never known it 
do harm, though we have used it in almost eveiy case. The patient should 
be kept in the bath some ten, fifteen, or twenty minutes, or until the con- 
vulsive movements cease ; when taken out it is most convenient, and at 
the same time useful, to envelop it in a small, light blanket, or flannel, 
for a short time, before the clothes are readjusted. 

In cases where the attack of eclampsia is limited to a single convulsive 
seizure, we rarely have an opportunity of instituting any treatment for 
the paroxj^sm itself, since it is usually over before we reach the patient. 
In such instances, bloodletting is unnecessary. If, however, the oppor- 
tunity offers, and if the convulsion occur in a strong and vigorous subject; 
if it be violent, and accompanied by a deep red, or yet more b}^ a livid 
flush of the face, and distension of the veins of the head and neck ; if it last 
more than a few minutes, or is repeated after short intervals of quiet, we 
would, without hesitation, recommend the use of bloodletting. The detrac- 
tion of blood is called for, in our opinion, for the same reasons as in puer- 
peral convulsions, and indeed in every violent convulsive attack, — to save 
the nervous centres from the effects of the parox3'sm, which are in all se- 
vere cases, excessive congestion, and, in some, fatal effusions. There are, 
however, many cases in which we would not advise depletion; as, for in- 
stance, those in which the convulsion depends upon an anaemic condition, 
and in which it is contraindicated b}^ a naturally feeble, or by a debilitated 
state of the constitution ; those in which it is clearly unnecessary, from the 



TREATMENT. 507 

slight severity or short duration of the attack; or those which occur in the 
course of other diseases, and particularly at their termination, and in which 
a resort to it is rendered evidently improper by the circumstances of the 
concomitant affection. The quantity of blood to be taken, and the method, 
must depend on the circumstances of the case. We must be guided as 
to the quantity by the age and constitution of the patient, the violence 
and duration of the paroxysm, and the cause of the attack. In a strong, 
hearty child, two or three } r ears of age, in whom the attack is violent, and 
produced by some cause not likely to continue long in action and thereby 
exhaust the strength, we may take from two to four ounces at the first 
bleeding; and should this fail to exert an influence upon the parox} T sm, a 
rather smaller quantity maj r be taken in one or two hours afterwards. 
In younger children, and those who are somewhat feeble or delicate, the 
amount drawn ought to be less. Usually speaking, venesection is to be 
preferred; but when a general bleeding cannot, from any cause, be em- 
ployed, we may resort to cups and leeches to the temples or back of the 
neck, or, as advised b3^some of the French writers, to more distant parts. 

We believe it is useful in all cases of essential and sympathetic convul- 
sions, which resist the employment of a warm-bath and bleeding, and also 
when bleeding is not resorted to, to make use of an emetic of some kind. 
The act of vomiting alone is often sufficient to break up a paroxysm of 
convulsions which has resisted various other means. This we learned 
first from the advice of an old and experienced practitioner, who was in 
the habit of employing emetics in all cases of eclampsia of children, and 
we have since seen it tested on numerous occasions. Dr. Hall recommends 
the induction of vomiting in the treatment of the paroxysm of the croup-like 
convulsion or laryngismus stridulus, and as a means of prevention in epi- 
lepsy. In the former he employs irritation of the fauces by tickling with 
a feather; in the latter, ipecacuanha. He says that a new mode of action 
is induced in the true spinal system by the act of vomiting, so that the 
disposition to closure of the larynx, and expiratory efforts, is exchanged 
for sudden acts of inspiration. The emetic which we employ is ipecac- 
uanha. The employment of emetics is generally advisable, even when 
there is no evidence that the attack is due to the presence of undigested 
or irritating substances in the stomach, since in cases of sudden eclampsia 
the cause is so frequently some gastric irritation. Of course, when there 
is special reason to suspect the presence of such a condition, the indica- 
tion for the administration of an emetic is even more positive. 

In addition to warm baths, bleeding, and emetics, cold applications to 
the head will be found proper and useful in nearly all cases which are of 
any considerable violence. Their use would be improper, however, when 
the surface is pale, the features contracted, and the pulse small and feeble ; 
but whenever the skin, especially that of the head, is deeply colored and 
turgid, and the pulse full and strong, they ought to be employed from the 
beginning. While the child is in the bath, its head may be wrapped in a 
cloth wet with ice-water ; or, after it has been removed, cold water may be 
poured from pitchers or a tea-kettle upon the same part. If the latter is 
done, enough should be emploj^ed to prevent the sudden reaction which 



508 ECLAMPSIA. 

inevitably takes place when but a small quantity is used. During the 
after treatment of the case, the cold applications ought to be continued 
so long as the head remains unnaturally heated. 

The administration of a purgative dose is proper and useful in most 
cases of convulsions ; particularly when it is found upon inquiry that the 
child has been constipated prior to the attack; when it is suspected that 
the bowels ma} 7 contain crude food or some foreign bod} 7 ; when it is de- 
sirable to produce an evacuant effect in a strong plethoric child, or a 
derivative action from the brain, and when the attack is attended with 
violent determination of blood towards that organ. The best purgative 
in severe cases occurring in hearty children is calomel. It is advantage- 
ous because of its easy administration, its speedy operation, and the 
powerful sedative influence which it exerts upon the whole economy. The 
dose should be from three to six grains, according to the age. It ought 
to be followed in one or two hours by some other cathartic, which may be 
either castor-oil, rhubarb, jalap, or salts. The best of all is castor-oil if 
it can be given. When the attack is slight or the patient weak and deli- 
cate, castor-oil is particularly applicable, as it operates with so little irri- 
tation to the intestine, or we may employ a mixture of castor-oil and 
spiced syrup of rhubarb. Whatever the remedy may be, it should be 
given only in such quantity as to produce complete evacuation of the 
bowels and a moderate derivation upon those organs, without the risk of 
occasioning a degree of irritation sufficient to increase the disturbance of 
the nervous system already existing. 

In man3 T , indeed, in most cases of eclampsia it will be found that pur- 
gative enemata are of great service. The} 7 may be administered imme- 
diate^ before or after the bath, and not unfrequently have the effect of 
stopping the paroxysm. They may consist of water holding in suspension 
or solution castile soap, common salt, molasses, castor-oil, sweet-oil, or 
spirits of turpentine. If the first fails to operate in ten or fifteen minutes, 
another or even a third ought to be given. 

Revulsives are of the utmost importance in the treatment of convul- 
sions. They should be employed from the very first, or immediately after 
the use of the bath. In slight attacks, they alone are often sufficient to 
suspend the paroxysm, or at least the fit often ceases under their use. 
Mustard is the most useful and convenient form of application in the 
great majority of cases. It may be used either in the form of sinapisms, 
which are to be shifted from place to place, or in that of the foot-bath. 
When sinapisms are used, they should alwa} r s be covered with gauze or 
fine muslin, to avoid the danger of leaving any of the mustard upon the 
skin after they are taken off. We once saw very bad ulcerations upon 
the feet of a child from the neglect of this precaution. In the hurry and 
bustle of the moment, the feet were not washed when the plasters were re- 
moved, and the mustard that remained produced vesications which ulcer- 
ated. In obstinate attacks, the revulsives ought to be reapplied from time 
to time, taking care to shift their position in order to avoid vesication. 

Antispasmodics are highly recommended by some writers upon the dis- 
ease, and particularly by M. Brachet, who appears to have used with ex- 



TREATMENT. 509 

eellent effect the oxide of zinc in combination with extract of hyos- 
eyamus. We have had but little experience in regard to their use, but 
confess ourselves indisposed to resort to them except after the employ- 
ment of the means already detailed ; during the intervals between the 
fits, when these occur from time to time ; and as a means of prevention 
in children threatened with the disease. There can be no doubt, from 
the evidence adduced in regard to their effects, and from what we have 
ourselves seen of the influence exerted by valerian upon the convulsive 
phenomena of acute cerebral diseases, that they have a considerable 
power of allaying the disorder of the locomotive apparatus present in all 
convulsive affections. As a means of prevention, therefore, as adjuvants 
to other remedies, and in children of very nervous, irritable temperament, 
and delicate constitution, in whom it is improper to use the more power- 
ful agents already detailed, we would advise a recourse to substances of 
this kind. The ones mostly highly recommended are valerian, oxide of 
zinc, assafcetida, and camphor. Of these, valerian or assafcetida are the 
ones we have usually employed. Valerian is best given in the form of 
the fluid extract, of which from ten to twenty drops may be administered 
in water, to a child two years old, every half hour or hour, until several 
doses have been exhibited, after which it ought to be suspended for a 
while or given in smaller quantity. Assafcetida is best given in the form 
of emulsion, half a teaspoonful being administered by the month, or one 
or two teaspoonfuls mixed with a little warm water may be thrown from 
time to time into the rectum. M. Brachet gave the oxide of zinc in com- 
bination with extract of lrvosc3~amus, to the amount of at least two grains 
of the former and four of the latter in twenty-four hours, divided into four, 
eight, or twelve doses. A dose was given every two or three hours, and 
when the symptoms were very violent, the first two or three were repeated 
at much shorter intervals. He says, speaking of this remedy ( Traite 
Prat, des Convulsions dans VEnfance, deux, edit., p. 402-3), U I always 
found it to produce quiet ; but whilst the cause remained, the quiet was 
only momentaiy, and the remedy seemed to have produced no effect. . . . 
This remedy does not destroy the cause (of the convulsion), but it allows 
time to treat it by calming the nervous erethism." 

Opium is a remedy which requires much care and discrimination in 
its employment, but which, in certain conditions of the disease, is of the 
greatest service. It should not generally be given while there remain 
any evidences of considerable determination of blood to the brain, but 
when this condition does not exist, or after it has been removed by blood- 
letting and revulsives, opium proves very useful in allaying irritability 
and restlessness, which themselves seem to keep up a disposition to a 
return or continuance of the convulsive phenomena. Somnolence also, 
and still more, coma, likewise contraindicate the use of opium. Dr. 
Eberle thinks he has seen much advantage from frictions over the spinal 
region with a mixture of equal parts of oil of amber, laudanum, and spirits 
of camphor, particularly in very young infants. 

Chloroform has been highly recommended in the essential convulsions 
of children, by Sir J. Y. Simpson (Edin. Med. Jour., June, 1S5S), and is 



510 ECLAMPSIA. 

favorably spoken of by both West and Trousseau. It should be used when 
the fits are violent and recur frequently, and do not yield to any of the 
remedies previously mentioned. By careful administration, anaesthesia 
may be prolonged for many hours, though, as Simpson recommends, it 
should be allowed to partially pass off every two or three hours for the 
purpose of feeding the child. It has been employed in numerous cases 
with the effect of arresting the convulsions, and in no instance has any 
unfavorable result been observed to follow its use. 

Bromide of potassium which has of late been so successfully employed 
in the treatment of almost all forms of convulsion, may be given with 
advantage, especially when the convulsions continue to recur at more or 
less regular intervals. It ma}^ be given in doses of one or two grains, 
three or four times daily, from the age of six months to one year, with 
an additional grain for every year. 

We shall here conclude our remarks upon the general treatment of 
eclampsia, and proceed to make some observations on the conduct to be 
pursued under particular circumstances. 

It is always highly important for the direction of the treatment, to dis- 
cover the cause of the attack. This is sometimes very easy, while in other 
instances it is exceedingly difficult, and not unfrequently impossible. If 
the attack occur in the course of some acute disease, as pneumonia, 
catarrh, angina, enteritis, or dysentery, or during the progress of one of 
the eruptive diseases, the diagnosis of the case is, as a general rule, very 
eas}~. If, on the contrary, it occurs at the commencement of one of these 
affections, the diagnosis will be much more difficult, unless indeed the 
symptoms of the concomitant disease have already declared themselves, or 
should do so very soon after the convulsion. The treatment in such cases 
should be that laid down in our general remarks, modified, however, by 
the requirements of the particular disease during the course of which the 
eclampsia occurs. 

When the attack occurs suddenly in a child previously in good health, 
or who had been merely slightly ailing for a few hours, the detection of 
the cause is still more difficult. The most probable causes under such 
circumstances are, however, dentition, indigestion, intestinal disorder, or 
the approach of an acute general or local disease. It is easy to determine 
by inquiry of the attendants, and by examination of the mouth, whether 
the child is teething or not. As a general rule, the convulsions which 
depend solely on the process of dentition, are slight, and last but a short 
time. In all the instances that we have seen, in which such was the only 
cause to be detected, the attack was of this nature. The treatment in 
such instances is to lance the gums, if they are swelled and inflamed over 
the advancing teeth ; to use warm baths, and to administer purgative 
and then antispasmodic enemata. These simple means will seldom fail 
when eclampsia depends on the process of dentition alone. But when, on 
the contrary, there is present indigestion, intestinal accumulations, or 
enteritis, as often happens during dentition, the case becomes more seri- 
ous, and requires in addition to the treatment above described, one 
directed to the particular coexisting morbid condition. 

The existence of indigestion as the cause of the attack, can be discov- 



TREATMENT. 511 

ered only by ascertaining with great care the diet of the child during the 
previous days. If it appear that something of an indigestible nature has 
been eaten within a short time, and if, at the same time, it be impossible 
to detect any more evident or probable cause for the attack, we should 
have a right to conclude that it depends upon indigestion. Under these 
circumstances the proper treatment is the immediate use of the warm 
bath, and the earliest possible administration of an emetic of ipecacuanha. 
The operation of the emetic ruay- often be hastened by tickling the fauces 
with a quill. If the paroxysm be very severe and long-continued, bleed- 
ing ought to be resorted to. 

The presence of intestinal accumulations as the cause of the paroxj^sms 
may be inferred, when it is found upon inquiry that the patient has been 
constipated for some days, or that the stools have been scanty and hard, 
or scanty and very offensive ; when the abdomen is distended and hard, 
and the distension is ascertained by palpation and percussion, not to be 
merely tympany ; and lastly, when there is no more evident cause for the 
attack. In such a case the particular treatment is the use of purgatives 
and enemata, in addition to the other means detailed. 

If the child presents the symptoms of dyspepsia and malnutrition, as- 
sociated with anaemia, and the convulsions recur during a long period, 
the most scrupulous care must be taken to secure a nutritious, digestible 
diet, combined with the use of tonics and iron. 

The dependency of the attack on the approach or commencement of 
some acute general or local disease, can be inferred only from a very 
careful examination of the antecedent and present phenomena of the case. 
One of these may be suspected as the cause when we can account for 
the occurrence of the convulsion on no more reasonable supposition ; 
when neither dentition, indigestion, nor intestinal irritation exist. It is 
scarcely likely that a convulsion could be occasioned hy any of the acute 
thoracic or abdominal affections, unless the disease had already gone far 
enough to allow a careful examination of the different rational and physi- 
cal s}-mptoms, to determine its existence. Perhaps the most difficult 
cases to diagnosticate, are those which occur at the beginning of the 
eruptive fevers. Even here, however, a careful search for the prodromic 
symptoms of the disease, a watchful observance of the condition of the 
patient in and after the paroxysm, will generally lead to a correct opinion 
within a few hours, or after a day, and sometimes at the moment of the 
attack. Of the eruptive diseases, scarlet fever is much the most apt to 
be accompanied by convulsions at the onset, and in that disease the re- 
markable rapidity and activity of the pulse, the state of the fauces, the 
heat of skin, and early appearance of the eruption, will generally enable 
us to understand the cause of the convulsion at a very early period. 

The treatment of sympathetic eclampsia depending on acute thoracic 
or abdominal disease, should be that which is proper for the particular 
malady which they complicate, with the addition of warm baths, revul- 
sives, antispasmodics, and, after depletion, of opium, in the form of 
Dover's powder combined with nitre. The management of the convul- 
sions which complicate the eruptive fevers, will be specially treated of in 
the articles on those maladies. 



512 LARYNGISMUS STRIDULUS. 

ARTICLE TO. 

LARYNGISMUS STRIDULUS. 

Definition; Synonymes ; Frequency. — Laryngismus stridulus he- 
longs to the class of neuroses. It is characterized hj crowing inspira- 
tions, or by momentary suspensions of the act of respiration ; these 
attacks occur suddenly, and at irregular intervals, are of short duration, 
cease suddenly, and are unaccompanied by cough, or other signs of irri- 
tation of the larjmx. If the disease progress, it becomes associated with 
other convulsive symptoms, as strabismus, distortion of the face, carpo- 
pedal spasms, or general convulsions. 

It is " the peculiar species of convulsion " of Dr. John Clarke ; the in- 
ward fits of Underwood; the spasm of the glottis of Marsh, West, and 
Yogel ; the laryngismus stridulus of Good ; the croup-like convulsion of 
Dr. Marshall Hall ; child-crowing; the spasme de la glotte of some of the 
French writers ; one form of the internal convulsion of MM. Trousseau 
and Pidoux, of MM. Rilliet and Barthez, and of J. L. Smith ; and the 
tlrymic asthma of some of the German authors. It is not mentioned by 
Dewees. It is described by Eberle under the title of carpo-pedal spasms. 

The frequency of the disease seems to vary in different countries. In 
France it would appear to be somewhat rare. MM. Rilliet and Barthez 
(2eme edit.) speak of having seen nine cases. At the time of publication 
of their first edition, they had met with only one case, and then stated 
that they were acquainted with only one other, published by M. Constant 
in the Bulletin de Therapeutique. M. Blache (article Xexroae du Larynx, 
Diet, de JJed., t. xvii, p. 590) adverts very cursorily to one case. M. Yal- 
leix (Guide du Med. Prat., Art. Asthme Thymique) doubts its existence 
as a distinct disease. In Germany, on the contrary, it would seem to be 
a rather frequent disease. In England it cannot be veiy infrequent, since 
Merriman says it is by no means uncommon. Copland (Stridulous 
Laryngic Suffocation in Children, Diet, of Prac. 3Ied.), speaks of numer- 
ous cases that he has seen, and states that- he has had as many as three 
under treatment at the same time. Le} 7 speaks of having met with con- 
siderably above twenty cases. Dr. Marshall Hall remarks that " within 
the short space of one month, I have seen five cases of croup-like convul- 
sion." Dr. Charles West (4th edit., p. 162) mentions thirty-seven cases of 
which he has preserved some record. 

We do not think it is a common disease in Philadelphia, though it is 
certainly not extremely rare, since we have seen four cases ourselves, 
and know of the occurrence of two other cases that proved fatal, and of 
two cases of recovery. 

Predisposing Causes. — Age. — It is generally acknowledged that the 
disease occurs most frequently during the period of the first dentition, 
though it has been known to occur as late as six or seven j'ears of age. 
Of 21 cases (17 from authors, and 4 by ourselves), in which the age is 



PREDISPOSING CAUSES. 513 

given. 9 were six months or less of age, 6 between six months and a year, 
4 between one and two years of age, 1 of two, and 1 of four } T ears of 
age : so that of the 20, fifteen were under one year. It is evident, there- 
fore, so far as these eases go, that the majority occur within the first, and 
very few after the second year. 

Of the 3T cases mentioned b} T Dr. West, 31 occurred in children between 
six months and two years of age. All the cases seen by MM. Rilliet and 
Bartkez were in children under two years old. Those authors state that 
the seven subjects observed by M. Herard were more than two years of 
age, and that two of them were between three and four j^ears old. From 
the statements made b} T authors in general, it would seem to be most fre- 
quent between the ages of three weeks and eighteen months. It has been 
known, however, in one very rare instance, to occur as late as seven years 
of age. 

Sex. — It is most frequent in the male sex. Of 50 cases (45 from 
authors, and 5 by ourselves), 39 occurred in boys, and 11 in girls. MM. 
Rilliet and Barthez state that of 16 cases observed by themselves and by 
M. Herard, 12 occurred in bo}'s, and 4 in girls ; of 183 cases collected by M. 
Lorent, in which the sex was noted, 125 occurred in boys, and 58 in girls.. 

Constitution. — Authors who have written on the disease generally ex- 
press the opinion that it is most frequent in children of nervous tem- 
perament, in those who are delicate and feeble, and especially in those- 
of scrofulous or rickety constitutions. It is nevertheless acknowledged 
that it sometimes occurs also in the most healthy and vigorous subjects- 
It not unfrequently attacks several children in a family. Ley quotes four 
instances from other writers, in which three children in each family had 
the disease, and in one all three died. He states that his own experience 
fully confirms this fact. 

MM. Rilliet and Barthez (2eme edit., note, t. ii, p. 52T) state that Davies 
and Henrich have met with four, and Torgord five children of the same 
family affected with the disease. They quote from Reid the curious fact 
that Powell saw one family of thirteen children, not one of which escaped: 
the disease. 

Amongst the causes of the disease, in addition to those already men- 
tioned, must not be forgotten dentition and improper food. These two 
are, indeed, probably the most influential of all in the production of the 
complaint. The age at which it occurs most frequently, the last half of 
the first, and the first half of the second year, the very period during, 
which the process of dentition is most active, would alone go far to show 
that this must constitute one of its most powerful predisposing, if not 
exciting, causes. The opinions of writers on this point are also conclu- 
sive as to the great influence of this vital process. Improper food, and 
especially early weaning, and the attempt to bring the child up on hand, 
is clearly a potent predisposing cause of the disease. This has been 
clearly shown in the cases that have come under our own observation, 
and especially in one in which contraction with rigidity followed the symp- 
toms of laryngismus. The details of this case will be found appended to 
the article on contracture. Dr. James Reid, in an excellent work on the 

33 



514 LARYNGISMUS STRIDULUS. 

disease (see Brit, and For. Med. Chirurg. Rev., Juty, 1849, p. 163), gives 
the following conclusions as to its etiology : " 1. That for the occurrence 
of this complaint, the cerebro-spinal system is required to be in a pecu- 
liarly excitable state, which then acts as a predisposing cause. The period 
of teething is the most likely to produce this condition. 2. That during 
this irritable state of the nervous centres, the two most frequent (and in 
the majority of instances the combined) causes are the improper descrip- 
tion of food which is administered to the infant, and the impure and irri- 
tating atmosphere which it breathes." 

Nature and Exciting Causes; Forms. — Much difference of opinion 
has prevailed in regard to the nature and exciting causes of laryngismus 
stridulus since the disease has attracted the particular notice of the pro- 
fession. Kopp and other German authors ascribe it to compression of 
the respiratory organs by an enlarged thymus gland, while others of that 
nation, and some of the English and French writers, class it amongst the 
neuroses. Dr. Hugh Ley supposed it to depend on compression of the 
par vagum nerves by enlarged cervical and bronchial glands. Dr. Mar- 
shall Hall considers it to be a disease of the reflex system of nerves. 
Amongst the French writers, MM. Rilliet and Barthez regard it as a neu- 
rosis ; Yalleix and Trousseau treat of it as one form of convulsions in 
children ; Blache {Diet, de Med., t. xvii, p. 584), speaks of it as a neurosis 
of the larynx, which may be either sj^mptomatic or idiopathic. 

Before examining in detail the different opinions quoted above, which 
we propose doing, we will refer to the anatomical appearances of the 
malad}'. 

The mucous membrane of the air-passages, as a general rule, is found 
perfectly healthy, presenting neither redness, inflammatoi^ swelling, 
oedema, nor accidental products of any kind. The lungs are usually of 
the natural color and density, and crepitant. M. Herard (Bib. du Med. 
Prat., t. v, pp. 319, 320) observed that in several autopsies made b}^ him- 
self, the} T always presented one marked change from their natural con- 
dition, however, which was a very high degree of einplryseina, more gene- 
ral and strongly marked than in any other disease. This alteration is 
believed to depend, as it does in hooping-cough, upon the impediment to 
respiration which exists during the disease. MM. Rilliet and Barthez 
state, however, that eniplvysema was not present in any of their autopsies. 

The heart and great vessels of the thorax often, but not always, con- 
tained more blood than usual, as in asphyxia. 

M. Herard states that he has made very minute researches in regard to 
the condition of the nervous S} T stem, examining the brain and spinal mar- 
row, the pneumogastric, recurrent, and diaphragmatic nerves, and those 
of the extremities even, to their terminations, without, however, finding 
important lesions in any case. He excepts only serous effusion in small 
quanthrv, and evidently consecutive, in the ventricles and particularly in 
the membranes of the brain, and slight venous congestion of the same 
kind. The tissues of the brain and spinal marrow retained their ordi- 
nary consistence, and presented neither redness nor softening. 

The condition of the pneumogastric nerves has, however, been variously 



NATURE — CAUSES. 515 

reported by different authors, some having found them softened, others 
indurated. 

In some cases tuberculosis of the lungs or bronchial glands, has been 
observed. But as these, as well as all the other lesions mentioned, are 
not constant, they cannot be regarded as characteristic. In many in- 
stances more or less marked evidences of rickets are discovered upon 
the bones of the cranium, the ribs, or the long bones of the extremities. 

TVe will now examine as succinctly as possible the different opinions 
which have been advocated in regard to the causes of laiyngismus strid- 
ulus. These may be classed, it seems to us, under four heads. 1. Enlarge- 
ment of the thymus gland. 2. Enlargement of the cervical and bronchial 
glands. 3. Organic disease of the cerebro-spinal axis. 4. That which re- 
gards it as a simple neurosis, without appreciable anatomical alterations. 

1. Enlargement of the Thymus Gland. — That the disease is in some 
cases coincident with, if not dependent upon, this condition, is proved by 
the observations of Kopp, Hirsch, Haugsted, Kyll, and others. Hasse 
(Pathol. Anat., Syden. Soc. Ed., p. 384) says there can be little doubt that 
it sometimes depends upon this cause. 

It appears to us, however, that it has been clearly shown by M. Herard 
(Joe. cit., p. 320, 321), that the disease is entirely independent of any altera- 
tion of the thymus. That observer found that in six children between two 
and four j^ears old, dying of the affection, the gland weighed between half 
a drachm and a drachm in five, and four drachms and two scruples in the 
sixth. These cases alone show that the size of the gland varies greatly 
in different subjects attacked with the disease. M. Herard has examined 
the gland, with a view to the elucidation of this point, in sixty children 
dying with various diseases, between two and four years of age (the age 
of those who had died of the disease under consideration). In fifty he 
found that it presented the same arrangement, color, density, and weight, 
as in those who had perished with laiyngismus stridulus. All of these 
subjects exhibited the same aspect; they were pale, thin, and most of 
them exhausted by diarrhoea. In ten of the sixty the gland was much 
more voluminous, weighing from two to two and a half or five drachms, 
and in one instance an ounce and a quarter. The ten subjects upon which 
these observations were made, died of different diseases, croup, acute 
laryngitis, asthma, meningitis, and varioloid. All exhibited the appear- 
ances of strong and vigorous health ; the one which presented the largest 
gland was very fat, and so robust, that, though only twenty-two months 
old, he looked to be three or four years. It appears to result therefore from 
these researches, that the gland is liable to great variations of size, and that 
its size bears a veiy exact proportion to the force of the child, being small 
in those who are slightly developed, or emaciated by chronic disease, and 
voluminous in those who are vigorously constituted, or who have died of 
acute diseases. 

That the disease does not depend, at least in all cases, on this cause, is 
shown also by Haugstead (Arch, de Med., t. xxxiii, 1833, p. Ill), who re- 
ports the case of a girl, seven years old, in whom the gland weighed five 
ounces, and measured four inches long, and one and a half in thickness, 



516 LARYNGISMUS STRIDULUS. 

without its occasioning the least difficulty of breathing of any kind. 
That it occurs in children in whom the gland is very small, is shown also 
by Caspari and Pagenstecher (quoted by Hasse, loc. cit.). 

2. Enlargement of the Cervical and Bronchial Glands. — This condition 
as a cause of the disease, so strongly advocated by Dr. Ley, and adopted 
upon his authority by Kyll and Hasse, would seem from certain facts and 
arguments to be of doubtful agency. 

Thus, Mr. Wakely (quoted by Kerr) states that "he possesses more 
than one case of tubercular affection in children, where the pneumogas- 
tric nerve has been completely flattened by the pressure of tubercles, 
without giving rise to an}' remarkable disturbance of the function of res- 
piration." Dr. Hall doubts the correctness of this explanation of the 
phenomena of the disease, and says that if the contiguity of enlarged 
glands with the pneumogastric nerve have an}- effect, it is hy their action 
upon it as an incident excitor, and not as a motor or muscular nerve. 

3. Organic Disease of the Cerebrospinal Axis. — That it may depend on 
this cause is proved by a case mentioned by Dr. Coley (On Infants and 
Children, BelVs edition, p. 226), who states that in a fatal instance which 
occurred in his own family, the only morbid appearance found on dissec- 
tion was a large exostosis growing on the inner surface of the occiput, 
which compressed the cerebelkfrn and produced chronic inflammation of 
the dura mater. 2so disease was discoverable either in the cervical or 
thoracic glands. Dr. Kyll (Arch. Gen. de Med., t. xiv, 1837, p. 94) quotes 
a case from Dr. Corrigan, of Dublin, which had lasted three months, in 
spite of calomel, emetics, and antispasmodics. Attention was called by 
chance to the spinal column, when it was discovered that pressure over 
the third and fourth cervical vertebrae was very painful, and produced 
loud cries from the child. Two applications of four leeches, at an in- 
terval of two da}'S, to that point, removed all the symptoms, and the 
child recovered perfectly. 

Dr. M. Hall (Diseases and Derangements of the Nervous System, 1841, 
p. 99) states that the crowing inspiration may arise from affections of the 
centre of the excito-motory system. He quotes a case related to him by 
Mr. Evans of Hampstead, of spina bifida, in which "there was a croup- 
like convulsion whenever the little patient turned so as to press upon the 
tumor." He states, moreover, that he found induration of the medulla 
oblongata in one case of the disease. 

Dr. West has also noticed occasional attacks of laiwiigismus stridulus in 
chronic hydrocephalus, occurring even before much enlargement of the 
head had appeared. 

4. That it is a Neurosis. — This is the opinion, according to MM. Killiet 
and Barthez, of Caspari, Pagenstecher, Roesch, and Hachman. It is 
also their own opinion, and that, as we have alread} T seen, of MM. Blache, 
Herarcl, and Dr. M. Hall. 

That the disease is, in fact, in the great majority of cases, a simple neu- 
rosis, is proved, we think, by the opinions just quoted, by the autopsies 
of M. Herard (already referred to), and by a case published by M. Con- 
stant, and cited by M. Blache (loc. cit., p. 584). This was the case of a 



NATURE — CAUSES. 517 

boy twenty-one mouths old, who was taken to the Children's Hospital at 
Paris, with well-marked symptoms of laryngismus stridulus, and who died 
there some days afterwards of small-pox. At the autopsy the larynx and 
brain were found to be healtlry. Merriman also relates two cases in which 
the children died in fits, both of which were examined by a skilful anato- 
mist, but i; not the slightest appearance of cerebral affection " could be 
discovered. 

That it is not always, however, a neurosis, is also shown by the cases 
quoted under the first head from Drs. Hall and Coley, and by those in 
which the disease is accompanied from the first by symptoms of inflam- 
mation or congestion of the brain. 

It has now been shown that the causes of the disease are exceedingly 
variable and uncertain, and that any opinion which asserts its depend- 
ence on one invariable and constant cause is untenable. We must, there- 
fore, seek some explanation which shall reconcile, as far as possible, the 
facts related above, and harmonize the various opinions expressed by the 
authors quoted. 

It seems to us that the explanation given by Dr. Hall (loc. cit.), is the 
only one which accounts satisfactorily for the phenomena of the dis- 
ease, and reconciles the contradictory accounts of its nature and causes 
brought forward. Dr. Hall regards it as an affection of the excito-motory 
or true spinal system of nerves, producing in mild cases partial closure 
of the glottis, and difficult inspirations, while in more severe cases the 
spasmodic disposition extends to other parts of the body, — to the eye- 
balls, and to the flexors of the fingers and toes. We have already alluded 
to his theory that in very violent attacks of laryngismus, where the 
glottis is entirely shut, the suspension of respiration produces conges- 
tion of the nervous centres and general convulsions. As already- stated, 
however, this theory has not been accepted, and we regard the occasional 
occurrence of general convulsions in connection with laryngismus strid- 
ulus, as one proof that this latter affection is merely a partial and imper- 
fectly developed convulsion. 

The causes may be either centric, seated in the nervous centres, or cen- 
tripetal, in the excitor or incident nerves. In the great majority of cases, 
the causes are centripetal, consisting of various • morbid conditions situ- 
ated at the peripheral extremities of the nerves, which become causes 
in consequence of the irritation they establish in the nerve-extremities : 
this irritation is transmitted to the nervous centres, and thence reflected 
through the various efferent or motor nerves to the different portions of 
the muscular apparatus affected in the disease, the larjmx, face, extremi- 
ties, and lastly, in severe casesj the whole body. The principal causes of 
this class are dental irritation occurring during dentition ; gastric irrita- 
tion, arising from excessive or improper food ; intestinal irritation from 
constipation, intestinal disorder or catharsis ; and perhaps the pressure of 
an enlarged thymus or of enlarged cervical or bronchial glands. 

The centric class of causes includes such as are seated in the nervous 
centres. These are much less common than the former class, and give rise 
to a vastly more dangerous and intractable form of the disease. They are 
different morbid conditions of the brain and spinal marrow, as inflamma- 



518 LARYNGISMUS STRIDULUS. 

tion, congestion, and effusion. That such causes sometimes produce the 
disease is shown by the case of exostosis already quoted from Coley, that 
of spinal irritation from Kyll, that of Dr. Hall, in which he found indura- 
tion of the medulla oblongata, and the one of spina bifida reported to Dr. 
Hall by Mr. Evans. In the latter case the tumor was seated on the loins. 
Mr. E. proposed to treat it b} T compression, but on making the attempt 
found that it was followed immediately " by the affection described by 
Dr. J. Clarke" (Hall, loc. cit., p. 144). Other centric causes are passion, 
vexation, fright, contradiction, &c, &c. 

This theory of the nature of the disease likewise accounts for the vary- 
ing character of the convulsive S3 T mptoms. The laryngeal spasm, from 
which the disease derives its name, does not constitute the whole malady; 
it is only one of the sj-mptoms, though the principal one, and that by 
which it is particularly characterized. The other convulsive phenomena, 
which generally occur only in severe attacks, or after the disease has 
continued for some time, are distortion of the face, strabismus, carpo- 
pedal spasms, and general convulsions. The hydrocephalic symptoms 
which occur towards the termination of some cases, and the serous effu- 
sion within the cranium found after death, are, it ought to be recollected, 
often the consequences of the congestion of the brain and asphyxia, 
which take place during the more or less complete closure of the larynx. 

Symptoms ; Course ; Duration. — Laiyngismus stridulus begins sud- 
denly with a parox}'Sm of difficult respiration. The laiynx is contracted 
spasmodically, and the entrance of air into the lungs is either prevented 
or impeded. In most cases the closure of the larynx is onlj r partial, and 
the respirator}^ movement continues, but is accompanied by prolonged and 
difficult inspirations, which give rise to the crowing or stridulous sound, 
whence the disease derives its name. The crowing sound is generally 
heard several times in each paroxysm, owing to the repeated but only 
partially successful attempts at inspiration; while in very violent cases it 
occurs only at the beginning and end of the accession, the respiration 
being entirety suspended in the middle period. At the same time the 
child presents an appearance of great distress. The body is thrown for- 
cibly backwards, the eyes are fixed and staring, the nostrils dilated, and 
the whole countenance indicative of great anxiety. If the paroxysm 
continues inany seconds, the face becomes bluish, the extremities cold, 
and the fingers and toes contracted. After a few seconds, or a minute, 
or even longer, the spasm of the larynx ceases; a loud, full inspiration 
takes place ; a fit of crying generally follows, and the child either very 
soon regains its usual spirits, or, if the paroxysm have been verj 7 severe, 
seems weak, languid, and drows}^ and returns more slowly to its ordinary 
condition. Between the parox3 T sms the child may seem perfectly well so 
far as concerns the character of the respiration, but it almost always 
exhibits the symptoms of some derangement of the general health, or, in 
other Avords, of the morbid condition which is the ultimate cause of the 
laiyngeal spasm. 

The paroxysms are most apt to occur during sleep, or as the child is 
waking. The}^ occur spontaneously, and are brought on b}^ fretting or 
crying, coughing, fright, contrarieties, deglutition, by the sudden appli- 



SYMPTOMS. 519 

cation of cold, and other sudden impressions. At the commencement of 
the disease they recur at rare intervals, and often attract little notice ; 
but, as the case progresses, the}' become more frequent, and may amount 
to twenty or thirty in the day, according to Kerr. They sometimes cease 
entirely for some weeks, or even months, and then recommence. In a case 
attended by one of ourselves (reported in the Am. Jour. Med. 5c?'., April, 
1S4T. p. 287), the attacks lasted eighteen days, occurring sometimes two 
or three times in an hour, and sometimes much less frequently. The 
child then recovered entirely for a period of seven months, when the dis- 
ease returned, and after continuing for five days, caused the death of the 
child in one of the paroxj^sms. 

If the disease continues to progress, it almost always becomes asso- 
ciated with other spasmodic symptoms. The thumbs are drawn tightly 
into the palms of the hands, and the fingers clasped over them, which 
gives to the back of the hands a swelled and tumid look. At the same 
time the toes are strongly flexed under the feet, and the insteps look 
swelled like the backs of the hands. Sometimes the hands are bent on 
the forearms, and the forearms on the arms. There is often distortion of 
the face. In severe cases, or when the disease has continued for a con- 
siderable period, epileptiform convulsions make their appearance, and 
generally prove fatal. 

The disease is apyretic in a large majority of cases. When fever arises 
it almost always depends on the condition which has occasioned the dis- 
ordered action of the excito-motory system, or on some accidental com- 
plication. The pulse during the paroxysm is small, corded, rapid, and 
sometimes imperceptible. In the intervals it is natural or nearly so. 

Death may occur very early in the disease, or after some weeks, months, 
or according to Kyll, years. Yogel states (op. cit., p. 2T2) that "some- 
times even the very first attack terminates in death, and a seemingly per- 
fectly health}^ child may be carried off in a few seconds." In a case 
quoted by MM. Rilliet and Barthez, death took place at the end of three 
w r eeks, and in another, in twenty months. 

The duration is very uncertain. It generally, however, lasts several 
months. In one of our own cases it lasted eighteen days, then ceased for 
seven months, returned, and proved fatal in five days. In another case, 
the attacks of spasms returned from time to time, during a period of 
three weeks. In another case, the notes of which were obligingly fur- 
nished us by our friend Dr. Benedict, and which we shall append to this 
article, it lasted, in connection with contracture, four months and a half, 
and was followed by perfect recovery. 

Other Forms of Internal Convulsions. — We have, for the sake of clear- 
ness, limited ourselves so far in the present article, to cases where the 
spasm is confined to the muscles of the laiynx, when the attack might be 
called one of laryngeal convulsion. 

In other cases, however, the spasm may affect, either solely, or in con- 
junction with the larynx, the diaphragm and the respiratory muscles of 
the abdomen and chest. The most common form of internal convulsion 



520 LARYNGISMUS STRIDULUS. 

as described by Trousseau, "is characterized hy rolling upwards of the 
e3 T eballs, by an almost complete loss of consciousness, by extreme diffi- 
cult}' or impossibilit} T of deglutition, by irregular respiration, at times 
barely perceptible, or free, deep, and blowing, indicating that the dia- 
phragm and the respiratory muscles of the abdomen and chest are especi- 
&\\y affected." 

These internal convulsions majr be associated with partial or even gen 
eral convulsions of the face and extremities; more frequently, however, 
they are accompanied by more or less general tonic muscular contraction. 

In most cases, as indicated in the passage quoted from Trousseau, the 
muscles of the pharynx are involved, and there is marked dysphagia or 
utter inabilhVy to swallow. 

In some instances, also, the frequencj 7 , irregularity, and smallness of 
the pulse, and the irregular and tumultuous character of the action of the 
heart indicate, as pointed out b}^ Killiet and Barthez (op. cit., t. i, p. 510), 
that the organs of circulation probably share in the convulsion. 

The degree in which the laiynx participates in the attack varies much 
in different cases ; at times there is no obstacle whatever to the entrance 
or exit of air through its cavity, at others, the spasm of its muscles is so 
extreme that the passage of air is entirely obstructed ; whilst in still other 
cases, of which the one communicated to us by the late Prof. Pepper, and 
quoted at the end of this article, is an example, respiration is difficult and 
accompanied by a stridulous noise. 

The above description applies to those cases of internal convulsions 
where the convulsion is complete, and presents both the primary tonic 
contraction and the subsequent clonic spasms of the respiratory muscles. 

But in other cases, the attack consists merely of a sudden tonic spasm 
of the diaphragm and respiratory muscles of the abdomen and chest, fol- 
lowed b}~ a sudden and complete relaxation. The entire suspension of 
the respiration during the spasm would of course rapidly induce fatal 
asphyxia, but fortunately the attacks, as we have met with them, have 
usually been so brief as not to cause any dangerous s} T mptoms. 

These attacks are popularly known in this country, and were described 
in the last edition of this work, under the title of "Holding-breath Spells." 

We have met with a considerable number of well-marked cases of the 
affection, and believe it to be of quite common occurrence. It seldom 
happens that the physician is consulted in regard to it, as those who have 
charge of children in whom it occurs, almost always ascribe it to temper, 
and think it of but little moment. It appears to be the result of a sudden 
spasm of all the respiratoiy muscles, so that the child ceases for the time 
to breathe, from which circumstance, no doubt, it has received its name 
of "holding-breath spell." There is no stridulous sound, nor hoarseness 
of the cry, nor indeed sound of any kind. The face is contracted and 
bluish, the base of the thorax retracted and immovable, and the limbs 
violently agitated at first, and then stiff; after a few seconds, or perhaps 
a minute in severe cases, the spasm yields, the child instantly makes a 
full inspiration, unattended with stridulous sound, and generally bursts 
into a loud fit of crying, which lasts for a few moments, after which the 



DIAGNOSIS — PROGNOSIS. 521 

child seems perfectly well, or else the attack is followed by excessive 
paleness, with languor or prostration, lasting half an hour or even longer. 
The attacks recur with variable frequency; there maybe several in a da} 7 , 
or but one, or they ma}' occur only at intervals of several clays. The most 
frequent cause of the paroxysms is contradiction. They are determined 
also by fright, pain, and crying. They never occur spontaneously, and 
never during sleep, so far as we know. It is to be distinguished from 
laryngismus stridulus by the absence of the crowing sound, by its not 
occurring spontaneously or during sleep, and by the absence of carpo- 
pedal or other spasmodic symptoms. It is, we believe, a spasmodic affec- 
tion of respiration, analogous to, though not exactly similar to laryngis- 
mus stridulus. We have never met with it except during the period of 
the first dentition, and always in children of nervous temperament. The 
cases that we have met with all recovered, and in one only did the life of 
the child seem to be at all endangered. In this instance the paroxysms 
had recurred very frequently for eleven months, and on two occasions 
were terminated by slight spasmodic movements of the limbs, lasting 
only for a few instants, and unaccompanied by insensibility or other dan- 
gerous sj-mptoms. After these attacks the child was removed to the 
country, where he recovered perfectly. 

Diagnosis. — The only disease with which laryngismus stridulus is likely 
to be confounded is spasmodic laryngitis, or false croup. From this it 
may readily be distinguished by the absence of catarrhal symptoms, or 
fever ; by the fact that the paroxysms occur indifferently in the day or 
night, and that thej^ are much more frequent ; hy the duration of the 
paroxysms, which last only a few seconds, or more rarely a minute ; by 
the absence of cough or hoarseness of the voice, even during the height 
of the parox3 T sm ; by the occurrence of tonic muscular spasms, and con- 
vulsions ; and finally by the chronic course of the malady : the converse 
of all of which symptoms exists in spasmodic croup. 

Prognosis. — The prognosis of laryngismus stridulus is always serious, 
since even the mildest cases may terminate fatally in any one of the par- 
oxysms. It is, however, far from being so dangerous a disease as has 
been supposed by some writers, and amongst others M. Yalleix, who 
states that it is almost always fatal (Guide du Med. Prat., t. i, p. 564). 
Of 56 cases collected from Pagenstecher, Hachman, Le}^, Kopp, Hall, 
Constant, Rilliet and Barthez, Kyll, and 5 from our own observation, 
making 61 in all, 4 died of intercurrent or consecutive diseases, while of 
the remaining 5T, 32 were cured, and 25, or about 43 per cent, died of the 
malady itself. 

MM. Rilliet and Barthez quote from M. Lorent, the translator of Dr. 
Reid's work, the statement, that of 289 cases collected from various 
writers, 115, or rather more than 39 per cent., proved fatal. 

The prognosis given by the physician ought to depend in great measure 
upon the cause of the malady. When it depends on dentition, improper 
diet, or gastro-intestinal disease, the case will in all probability terminate 
favorably if the proper treatment can be, and is, brought to bear against 
those morbid conditions : while if it occur under the influence of a centric 



522 LARYNGISMUS STRIDULUS. 

cause, or of enlargement of the cervical or bronchial ganglions, the prog- 
nosis becomes much more unpromising. 

Treatment. — If the views taken of the nature of the disease in the 
above remarks be correct, it must be evident that for the treatment to 
offer any considerable chance of success, it must be directed not merely 
to the removal of the spasm of the larynx, which is only a s3 7 mptom and 
not the whole disease, but to the remedying of the deeper-seated cause of 
the disordered functional action of the excito-motory system of nerves. 

When dentition is ascertained to be the cause of the disease, the gums 
ought to be carefully watched, and freely scarified, so soon as there is 
the least heat or swelling over the advancing teeth. Dr. Marshall Hall 
deems the use of the gum-lancet one of the most important means of treat- 
ment we are possessed of, and recommends that the gums should be fully 
divided, " not once, or occasion ally, but twice or even thrice daily." In 
another place, he says : " We should lance the gums freely and deeply, 
over a great part of their extent, daily, or even twice a day, and apply a 
sponge with warm water, so as to encourage the flow of blood." He even 
recommends that in very urgent cases, the lateral as well as the more 
prominent portions of the gum, should be scarified. Lancing of the gums 
is undoubtedly a most important point in the treatment of this and other 
diseases of childhood, connected with dentition. We have long been con- 
vinced, however, from personal observation, that a resort to this opera- 
tion merely because the child is passing through the period of dentition, 
is at least useless. We have never found it to do any good, unless the 
teeth are near enough to the surface to produce manifest swelling, at- 
tended with heat and soreness of the gums. So long as the gum is hard, 
insensible, not turgid, and of its natural color, and the mouth not hot, 
cutting has done no good. 

When the disease depends on gastric irritation, the result of an un- 
healthy milk, or of artificial diet, our attention must be directed princi- 
pally to the removal of that condition. A wet-nurse ought to be procured 
at once if one can be obtained, and if the child will nurse. If this cannot 
be done the diet must be carefully regulated by the physician. Ass's 
milk or goat's milk ought to be used if they can be procured ; if not, we 
would recommend the gelatine diet prepared as recommended at page 
304. The proportion of the ingredients must be regulated by the condi- 
tion of the stomach. If the digestive power be very weak, the proportion 
of milk must be only a fourth or even a sixth for a few da} T s, while the 
amount of cream must bear its usual ratio to the milk. 

When the child is thin and pale, and the stomach evidently weak and 
dyspeptic, it is well to resort to small quantities of stimulants, and to tonics 
in proper doses. The best stimulant is fine old brandy, of which from 
ten to twenty drops may be given three or four times a day, or every two 
or three hours. Or we may administer the aromatic spirits of hartshorn in 
connection with, or without the brandy: of this about ten or fifteen drops 
should be given four or five times a da}', or alternately with the brandy. 
Of tonics, the most suitable, it seems to us, are quinine, in the dose of a 
quarter of a grain three or four times a day, or the citrate of iron and 



TREATMENT. 523 

quinine, in the dose of half a grain, given in the same way. Another 
very excellent stimulant and tonic is the Huxham's tincture of bark, of 
which about five drops may be prescribed in the place of brandy. This 
kind of treatment will scarcely fail to stimulate the digestive power of the 
stomach to greater activity after a few days, and of course to improve 
the nutritive functions and the strength of the patient. 

When the disease appears to depend on intestinal irritation, we must 
inquire carefully into its nature and causes. It may be connected with 
constipation, diarrhoea, or with an unhealthy state of the contents of the 
bowels. It is often dependent on the presence of crude or imperfectly 
digested food in the alimentary canal, and when this is the case, the only 
proper method of treatment is to attend to the state of the digestive func- 
tion, and to discover and employ a proper diet. The bowels are quite 
frequently very torpid, and the stools, when obtained by medicine, are 
often found to be very offensive, light-colored, and past}^, conditions gen- 
erally resulting from imperfect action of the liver. Under these circum- 
stances small doses of mercurials, or taraxacum, should be resorted to in 
combination with or followed by mild aperients, as castor-oil or rhubarb. 
One of the very best cathartic remedies, when this combination of symp- 
toms is present, is Chaussier's mixture of castor-oil aud aromatic syrup 
of rhubarb, consisting of three parts of the former rubbed up with five 
parts of the latter. The dose is a teaspoonful every two or three hours, 
until the bowels are well evacuated. It is gentle in its action, and yet 
very efficient, gives no pain, and is easily taken. If a mercurial be de- 
sired, about two or three grains of blue mass, one or two grains of calo- 
mel, or four grains of the mercury with chalk, may be incorporated into 
an ounce of the mixture. When diarrhoea is present, it must be treated 
according to its causes, as recommended in the articles on simple diar- 
rhoea and entero-colitis. When, on the contrary, constipation appears to 
be the cause of the disorder, this is to be treated by regulation of the diet, 
by the daily use of warm water enemata (particularly recommended by 
Dr. M. Hall), or, if these do not answer, by the exhibition of small doses 
of the mildest aperients. 

Dr. Hall states that by strict attention to the dentition process, and to 
gastric and intestinal irritation in the dawn of the disease, he has suc- 
ceeded in curing all the cases he has seen but one, and in that he found 
induration of the medulla oblongata. 

By those who suppose the disease to depend on enlargement of the 
thymic, cervical, or bronchial glands, it has been proposed to endeavor 
to procure a reduction of the hypertrophy of those glands by frequent 
applications of leeches, by the use of exutories upon the thorax, b}' the 
employment of strong purgative medicines, and by the administration of 
mercury, digitalis, and iodine. In a case apparently connected with en- 
largement of the bronchial or cervical glands, we should prefer to direct 
our treatment to the invigoration of the general health by attention to 
diet, by the use of tonics, and by proper exposure to fresh air, whilst we 
should employ internally, cod-liver oil, iron, iodide of potassium, the 
preparations of iodine, and antispasmodics. 



524 LARYNGISMUS STRIDULUS. 

When the disease depends on a centric canse, this must be treated, if 
it can be detected, according to its nature. 

Antispasmodics. — Whatever be the causes of laryngismus stridulus, it 
is undoubtedly proper, whilst our chief efforts are directed towards their 
removal or mitigation, to make use of antispasmodics in order to mod- 
erate the spasmodic sj'inptoms which are but the expression of those 
causes. The remedies of this class most highly recommended are cheriy- 
laurel water, belladonna, valerian, musk, assafcetida, oxide of zinc, and 
small doses of ipecacuanha. The most efficient are probably the oxide of 
zinc, which is recommended by M. Bracket (Traite Pratique des Con- 
vulsions dans V Enfance) as one of the best antispasmodics that can be 
used in the convulsions of children, the fluid extract of valerian, the 
preparations of belladonna, and aromatic spirits of hartshorn. M. Bra- 
chet alwaj's combines the oxide of zinc with extract of hyoscj-aums, and 
gives at least two grains of the former with four of the latter, in divided 
doses, in the twenty-four hours. He states that he has never given more 
than ten grains of each in the period mentioned. Of the fluid extract of 
valerian, about a teaspoonful, or even more, might be given in the twent}~- 
four hours, to a child one or two years old. It should be mixed with 
water, of course. The aromatic spirits of hartshorn may be given as 
recommended above. We would also recommend the use of the bromide 
of potassium in full doses. 

It must never be forgotten, however, that remedies of this class are 
to be employed only as palliatives and adjuvants, and not as curative 
agents. 

Iron. — Of all the remedies to be emphrved, after attending in the strict- 
est manner to the removal of the exciting causes of the disease, there is 
none of such almost universal applicabilit}' as iron or its preparations. 
The patient is almost invariably, owing to the faulty state of the diges- 
tive and nutritive functions, more or less ansemical, a condition impera- 
tively demanding iron ; and as this remedj T rarely conflicts with the other 
meam? indicated, it should be given probably in all, or nearly all the cases. 
The metallic iron in powder or in lozenges, in doses of half a grain or a 
grain three times a day, or the iodide of iron in doses of from two to four 
drops three times a day, in a mixture of syrup and cinnamon-water, are 
the best preparations, and they should be continued, as a general rule, 
throughout the treatment of the case. 

Treatment during the Paroxysm. — When the child is attacked with a 
paroxysm of difficult breathing, it should be lifted at once into a sitting- 
posture, if it be reclining, and fanned, or carried to an open window, if 
the weather be not too cold. At the same time cold water should be 
sprinkled upon the face, and if the attack be violent, we may resort to 
what is recommended by Dr. Hugh Ley and Dr. Hall, tickling of the 
fauces to produce nausea or vomiting, or irritation of the nostrils with a 
feather, so as to occasion gasping respiration. In a case which occurred 
to the late Dr. C. D. Meigs, accompanied with severe general convulsions, 
he found that the suspension of the respiration could very generally be 
broken in upon, and the parox} T sm sometimes averted by the application 



case. 525 

of a piece of ice, wrapped in a cloth, to the epigastrium and lower part of 
the sternum. 

Dr. Edmunds {Med. Times and Gaz., March 12, 1864) also found that 
the application of one of Chapman's ice-bags to the spine, did more than 
anything else to keep off the paroxysms in an obstinate case of laryn- 
gismus. 

To prevent congestion of the brain and effusion, which sometimes takes 
place as the effects of the attacks, Dr. Hall recommends a few leeches or 
cups to the head, the application of an alcoholic lotion over the whole 
head, or the use of the ice-cap. At the same time the bowels ought to be 
speedily moved by large enemata either of simple water or of water con- 
taining salt. 

In cases, especially of the more general form of internal convulsions, 
where the attacks are so frequently repeated and severe as to threaten life, 
we would recommend the induction of partial anaesthesia by either ether 
or chloroform, as advised in the article on eclampsia. 

Removal to the Country. — When the disease persists in spite of the 
means above recommended, and especially when it depends on dentition 
or digestive irritation, change of air will often produce a wonderful effect, 
and should always be tried. The good effects of removal from the city 
to the country are strikingly shown in the case communicated to us by 
Dr. Benedict. 

CASE COMMUNICATED BY DR. BENEDICT. 

" The subject of this case was a bo}^, born in July, 1845. He was a 
large, hearty child, and remained well until January, 1846, when his 
mother's milk failed, and he was placed upon artificial diet. From this 
time to May following, his diet was cream and water, barley-water, oat- 
meal, arrowroot, pounded crackers boiled with water, and gum-water, all 
of which were tried in turn, being prepared and administered with the 
greatest caution as to time and quantity. A wet-nurse was tried, but the 
child refused the breast entirety. 

" On the 2'7th January he was attacked with diarrhoea, which lasted 
one week. This was followed by constipation, the stools being white, 
firm, tenacious, and offensive. The constipation continued up to July, 
when it was replaced by diarrhoea. 

"February 4th, 1846. On this day, the child being seven months old, 
was first observed a spasm of the larynx, producing a shrill, croupal 
whistle, or ooh, ooh, during two or three successive respirations, and fol- 
lowed by a cessation of breathing for some seconds, long enough to dash 
water in his face, carry him to the window, pat him on the back, &c. 
These spells occurred during the sleeping and waking state, and espe- 
cially during crying or laughing, and continued almost daily and often 
many times a day and night until June, when he was taken into the 
country. 

" Simultaneously with the laryngeal spasm, appeared contractions of 
the upper extremities, the thumbs being drawn tightly into the palms of 
the hands, the fingers flexed over the thumbs, and the hands bent on the 



526 LARYNGISMUS STRIDULUS. 

forearms. The backs of the hands were swollen, and the skin looked 
tight and polished. 

" For a few days in the middle of February there was a subsidence of 
all the symptoms, with decided improvement in every respect. 

" On the 25th of the same mouth occurred a return of all the symptoms, 
with extension of the spasm to the feet, the toes being bent under the 
feet, the insteps much swelled and having a polished appearance. At the 
same time there were occasional spasmodic movements of the muscles of 
the face, arms, and bod}', resembling those of chorea. This condition 
continued with occasional relaxations up to the 11th of June. 

"The stomach was exceedingly delicate, rejecting the most carefully 
selected nourishment, and at times refusing all food. The child became 
pale, thin, and timid ; was disturbed b} T the slightest noise, and shunned 
the light as painful. 

"He was removed to the country on the 11th of June. There his 
health was gradually restored. The appetite improved, the spasm of the 
larynx and contractions of the extremities gradually relaxed, and the 
thumbs were at last liberated, the skin under them having taken on the 
appearance of mucous membrane. There was no return of the disease 
after the middle of June, although the child had a severe attack of diar- 
rhoea in July, after which he got perfectly well, and has remained so up 
to the present time (June, 1847). The first tooth made its appearance in 
September, and he now has fourteen, and has cut them all without the 
least accident. During the last eight months he has been remarkably fat 
and heart}'. 

" I am not aware that any medicine had any effect in removing the 
disease. Calomel, in large and small closes, antispasmodics of all kinds, 
frictions over the spine, blisters to the back of the head, alteratives, lax- 
atives, &c, were persevered in without benefit. On removing him to the 
country, and feeding him on milk warm from the cow, at first diluted, 
and afterwards pure, an improvement was speedily observed." 

Dr. B. adds : " There cannot, I think, be any doubt that the disease 
originated in the stomach, and extended to the bowels, perhaps the liver, 
and to the nervous system." 

Remarks. — The above case was evidently one of laryngismus stridulus. 
It must be clear to every one, we think, that the cause was seated, as Dr. 
Benedict remarks, in the digestive apparatus. The history of the case, 
the onset of the disease soon after the child was put upon artificial diet, 
the difficulty of finding food to agree well, the condition of the bowels, 
the offensive, bileless stools, the persistence of the case so long as the 
stomach continued feeble and the food improper, and the rapid improve- 
ment after the child had felt the invigorating influence of the country air, 
all seem to show conclusively that the difficulty was in fact disordered 
digestion. 

We would recommend those who wish to observe still farther the in- 
fluence of disordered digestion in the production of nervous disease, to 
peruse three cases detailed by Dr. Coley. (Pract. Treatise on the Dis. of 
Children, Bell's edition, pages 233, 234, 235.) 



case. 527 



CASE BY THE AUTHOR. 

The following case is one that occurred to one of ourselves. We ex- 
tract the account of it from a paper on croup by Dr. J. P. Meigs. (Am. 
Journ. Med. Sei., April, 184 1.) 

The patient was a girl, five months of age. We saw the child on the 28th 
of March, 1844. The first attack occurred the day before we were called, 
but as the mother supposed it to be a matter of little consequence, she did 
not send for me until the next day. The child was well grown, and except 
a rather too great paleness, looked strong and healthy. It was playful and 
good-humored, nursed freely, had no fever, and between the paroxysms 
presented the appearances of perfect health. The crowing fits occurred 
frequently in the course of the day and night, sometimes two or three times 
in an hour, or not so often. The}^ often waked the little thing suddenly 
from tranquil sleep. They consisted of a succession of long and difficult 
inspirations, accompanied by a peculiar whistling or crowing sound, such 
as might be supposed to depend on the passage of air through a narrow 
aperture. During the attack, the face assumed an expression of great 
anxiety, the respiratory muscles contracted with violence, and there 
seemed to be for the time imminent clanger of suffocation. After several 
seconds or a minute the shrillness of the sound diminished, the struggling 
subsided, and soon the respiration became perfectly natural, and the child 
seemed well. The parox} T sms were usually followed by fits of crying, 
which, however, were easily pacified. 

The paroxysms gradually diminished in frequency and violence, and 
ceased entirely after the 13th of April. The treatment consisted simply 
in careful attention to the general health, and in the frequent use of warm 
baths and mild nauseants. 

The child remained perfectly well, with the exception of a slight attack 
of cholera infantum, until the following November, seven months after, 
when the disorder recurred. Several paroxysms occurred between the 
12th and lTth of the month; but as they were slight and unattended by 
other symptoms of illness, the mother was not alarmed, and paid but 
little attention to them. On the lYth of the same month, the child was 
sitting on the floor amusing itself with some playthings. There were no 
persons in the room except young children. They saw the little thing 
stoop forward suddenly, as though in play, and did not therefore regard 
it immediately. As it remained in that position, however, they went to 
it, took it up, and found it dead. It had perished suddenly, no doubt in 
one of the paroxysms of crowing. 

An autopsy was made, in which the larynx and thoracic organs were 
examined, but nothing was found to explain the cause of the disease or 
the sudden death. 

In the following interesting case, communicated to us by the late Prof. 
William Pepper, the attack consisted of persistent laiyngismus stridulus, 
accompanied by frequently recurring internal convulsions affecting the 
diaphragm and other respiratory muscles, and by tonic contraction of 
the muscles of the arms. 



528 LARYNGISMUS STRIDULUS. 



CASE COMMUNICATED BY DR. PEPPER. 

" A boy, aged four months, remarkably healthy and well-developed, 
after suffering a few days with slight catarrhal symptoms, was suddenly 
seized with a peculiar stridulous crowing respiration. 

" I saw the child about half an hour from the commencement of the 
attack, and found it with a pulse of 140, pale face, and livid lips. The 
pupils were contracted, and the hands firmly clenched ; the crowing sound 
was very loud, and attended every act of inspiration. At times the res- 
piration and circulation would be entirely suspended for many seconds, 
followed by great lividity of the surface and coldness of the extremities. 

" Eight or ten leeches were applied behind the ears, the feet placed in 
warm water, and a dose of castor-oil administered, to be followed by 
saline enemata. 

" Four hours from the commencement of the attack, all the symptoms 
were greatly aggravated ; the wrists and fingers were firmly flexed, these 
spasms coinciding with the arrest of the circulation and respiration ; there 
was now perfect insensibility. The child was placed in a warm bath, cold 
water was applied to the head, and a sinapism along the spine, without, 
however, affording any relief to the crowing inspiration, or other spas- 
modic symptoms. 

"At the suggestion of Dr. C. D. Meigs, the child was now placed on 
its right side, with the shoulders elevated ; this position to be maintained 
at least six hours. At the end of that time the child was in no respect 
improved, and accordingly, at the suggestion of Dr. M., six leeches were 
applied over the cardiac region; f^i of lac. assafceticl. was thrown into the 
rectum, and a blister applied to the back of the neck. 

" The child expired at midnight, about ten hours from the commence- 
ment of the attack, the crowing respiration, with more or less asphyxia, 
having persisted throughout. 

"Autopsy thirty-six hours after Death. — Mucous membrane of the 
larynx injected, but in other respects natural. Thymus gland three and a 
half inches long, two and a half wide, and at its upper part three-quarters 
of an inch thick; its weight was 620 grains, or 10 drachms and 1 scruple. 
Lower lobes of both lungs greatly congested. Heart natural. The brain, 
unfortunately, could not be examined." 

It will be observed that, in the above case, the laryngismus and other 
spasmodic symptoms appeared after slight catarrhal symptoms had ex- 
isted for a few days ; and it may be possible that the irritation of the 
mucous membrane acted as the exciting cause of the convulsive at- 
tack. A recent author 1 has, however, alluded to the case in such a con- 
nection and manner, as to at least suggest that he may have mistaken it 
for one of spasmodic laryngitis. A careful consideration of the symp- 
toms and course of the case will, however, sufficiently show its essential 
difference from this latter affection. 



1 Dr. J. Lewis Smith {pp. cit, p. 199). 



DEFINITION — CAUSES — NATURE OF THE DISEASE. 529 



AETICLE VIII. 

CONTRACTION WITH RIGIDITY. 

This is the disease called by the French contracture. We shall treat of 
it as idiopathic contraction with rigidity. It has been little known until 
within a few years, and yet is clearly not a very rare affection in Paris, 
from the number of cases on record in different medical journals and 
works. We have met with but one well-marked example of it ourselves 
in this country. This case, of which we shall give a sketch at the end of 
this article, and the one of laryngismus stridulus communicated to us by 
Dr. Benedict, and appended to the article on that disease, furnish very 
good examples of contraction coexisting with the former affection. We 
have seen also two other cases in which the contraction was decided, but 
in which it lasted but a short time. 

The disease is evidently one of the forms of eclampsia, which assumes 
such a variety of shapes during infancy and childhood. Though it gen- 
erally exists as an idiopathic and distinct malady, it is in other cases asso- 
ciated with, or follows laryngismus stridulus or spasm of the glottis, and 
in others again is combined with attacks of general convulsions. 

Definition. — By idiopathic contraction with rigidity (contracture of 
the French writers), is meant the involuntary tonic contraction of differ- 
ent flexor muscles of the extremities, particularly those of the fingers and 
toes, but sometimes of the forearms and arms also, existing independ- 
ently of any appreciable organic disease of the cerebro-spinal axis. It 
has been described by different English writers in connection with laryn- 
gismus stridulus, under the title of "carpo-pedal spasms," "cerebral 
spasmodic group," " croup-like convulsions," &c, &c. We believe, how- 
ever, that it will be useful to describe it separately from that disorder, for 
though of the same nature, and sometimes associated with it, it often 
exists as an independent affection. 

Causes. — It is most common between the ages of one and three j^ears. 
It is much oftener sympathetic than essential, and its most frequent 
causes are dentition, disordered states of the digestive function depend- 
ent upon improper alimentation, anaemia and its accompanying nervous 
excitability, brought about by digestive and nutritive derangements, 
pneumonia, bronchitis, masturbation, and unfavorable hygienic condi- 
tions. In some few cases, the disease is truly essential, since no patho- 
logical cause for it whatever can be detected. It is merely necessary to 
say that it is often symptomatic of disease of the brain, but of that form 
of the affection nothing will be said in the present article. 

Nature of the Disease. — It appears to consist in a functional de- 
rangement of the motor tract of the cerebro-spinal axis, occurring with- 
out any cause that can be detected, or determined by the existence of 
some irritation affecting incident excitor nerves. We once saw a child 
two years of age, who, after a restless, uneas} r night, presented in the 
morning tonic contraction of the flexors of all the toes of both feet, so 

34 



530 CONTRACTION WITH RIGIDITY. 

that the insteps were swelled, and looked smooth and polished. There 
was no other sign of sickness except peevishness. Learning on inquiry 
that the bowels had been somewhat constipated for several days, and that 
the materials of the scanty stools which had been discharged were dark- 
colored and very offensive, we ordered a dose of castor-oil containing two 
grains of calomel. The contraction continued unj-ielcling until six o'clock 
in the afternoon, when a very copious, dark-colored, viscid, and offensive 
stool occurred, and the contraction immediately ceased. Here the cause 
of the contraction was evidently an accumulation of unhealthy fecal matter 
in the intestine, which, irritating certain sensitive fibres of the excito- 
motoiy sj'stem, caused a reflex motor action that gave rise to permanent 
muscular contractions. In other cases the disturbance of the excito- 
motory s} T stem depends on the irritation of excitor nerves occasioned by 
the process of dentition, by indigestion, by diarrhoea, pneumonia, pleurisy, 
,&c. In other instances, again, to which the term essential must be applied, 
it seems to depend simply on general debility and anaemia, which are well 
known to be productive of functional disease of the nervous system. 

Symptoms ; Course ; Duration. — The disease rarely attacks children 
previously in good health, but generally those already suffering -from 
some disorder of the general health, or a severe local affection. When 
sympathetic, the first symptom noted is the contraction which constitutes 
•the disease. When essential, on the contrary, the onset is sometimes 
marked by various nervous symptoms, such as giddiness, headache, or 
somnolence, which soon pass off, leaving the simple contraction with 
rigidity as the only morbid condition. In most cases, however, the attack 
begins with the muscular contraction, which generally affects the superior 
extremities first, and gradually extends to the inferior. 

When the disease is fully developed, the thumbs are drawn clown into 
the palms of the hands, and the fingers, strongly flexed at the metacarpo- 
phalangeal articulations, cover and conceal the thumbs. At the same 
time that the metacarpo-phalangeal articulations are flexed, the phalanges 
themselves remain extended and the fingers are separated- from each other. 
The contraction generally affects the wrist-joints also, so that the hands 
are strongly flexed upon the forearms, and in some rare cases the latter 
upon the arms. The disorder usually affects the inferior extremities 
likewise, the toes being in a state of tonic flexion or extension, the foot 
rigidly extended upon the leg, and its point sometimes drawn inwards. 
The spasm very rarely extends to the knees. 

Children old enough to describe their sensations generally complain of 
stiffness in the affected parts, with more or less severe pains darting along 
the course of the nerves. The contracted muscles are hard and rigid to 
the touch, and sometimes enlarged so as to appear in strong relief under 
the skin. In slight cases the .contractions can be overcome by very mod- 
erate force and without pain, whilst in those which are more severe, the 
attempt to overcome the contraction is productive of acute pain in the 
rigid parts. The backs of the hands and the insteps present .a swollen 
appearance, and the skin over these points is smooth and polished. In 
the case communicated by Dr. Benedict, appended to the article on laiyn- 



DIAGNOSIS. 531 

gismus stridulus, and likewise in our own case, the skin under the 
thumbs had assumed the appearance of mucous membrane, from the long 
and close confinement of the member. 

In addition to the symptoms already enumerated as characteristic of 
the malady, there are others which require attention. The child is of 
course unable to walk or perform anj T prehensile movement. The intelli- 
gence and senses always remain perfect in simple, uncomplicated cases. 
The nervous system shows signs of disorder in the form of restlessness 
or languor, and irritability, with crying and peevishness. In the great 
majority of instances, these are the only nervous symptoms, though in 
some there are general or partial convulsions, strabismus, and diminution 
of sensibilhy. Of these the most frequent is convulsions, which gen- 
erally come on a few days after the attack, or precede the fatal termina- 
tion. In the case of Dr. Benedict, referred to above, there were occa- 
sional choreatic movements of the face, arms, and body. The simple 
disease is unaccompanied by any febrile movement, and the organic func- 
tions go on naturally. In the sjanpathetic form, on the contrary, we have 
the various sj-mptoms of the disease which acts as the cause of the con- 
traction, whether that be abdominal or thoracic. The most common train 
of symptoms, in young children, is the same as that which accompanies 
gastric or intestinal derangement, dentition, &c. The course and dura- 
tion of the disease are very irregular and uncertain. When once devel- 
oped it may last from weeks to months, either slowly increasing in severity, 
or remaining stationary for a length of time. As a general rule, after it 
has lasted for some time, it becomes intermittent, sometimes diminishing 
or even disappearing entirely for a period, then reappearing or increasing, 
to subside or cease again, and so changing without regularity or evident 
cause, until at last recoveiy gradually- takes place, or death occurs from 
the concomitant disease, or in a paroxysm of convulsions. 

Diagnosis. — The only difficulty in the diagnosis of idiopathic contrac- 
tion is to distinguish it from symptomatic contraction, or that which de- 
pends upon cerebral or spinal disease. The kinds of cerebral disease 
which most frequently occasion contraction are tubercle of the brain, and 
meningeal hemorrhage. The distinction can generally be made with con- 
siderable facility, however, by attention to the various disorders of intel- 
ligence and sensibility, to the fever, constipation, vomiting, and different 
modes of invasion and progress which characterize the symptomatic form. 
The following table, taken from MM. Billiet and Barthez, will assist in 
the diagnosis. 

SYMPTOMATIC CONTRACTION. ESSENTIAL CONTRACTION. 

Cerebral symptoms, special functional Similar cerebral symptoms, but only in 

disorders (convulsions, strabismus, dilata- exceptional cases, sometimes acconipany- 

tion of the pupils, &c), preceding or ac- ing, but never scarcely preceding the con- 

companying the contraction. traction. 

In many cases irregularity of the pulse. No irregularity of the pulse. 

Generally partial, and commencing Binary, commencing in the fingers and 

usually in the elbows and knees, and in a toes, 
single extremity. 

Almost always permanent. Kemarkably intermittent. 



532 CONTRACTION WITH RIGIDITY. 

Prognosis. — The prognosis must depend on the cause of the malad}^. 
The contraction itself has no influence whatever on the termination. The 
fatal termination has always resulted from the anterior or concomitant 
disease. Six cases observed by M. Barrier all recovered. The case com- 
municated to us by Dr. Benedict, which was connected with laiyngismus 
stridulus, and one very severe one that occurred in our own practice, also 
terminated favorably. The prognosis is favorable, therefore, when the 
attack occurs in a child of naturally good constitution, and when the 
cause of the disease is not a permanent or incurable one. The possi- 
bility of the occurrence of fatal convulsions should alwa}^s lead us to 
make a guarded prognosis. 

Treatment. — The treatment must depend on the circumstances under 
which the disease has made its appearance. When it occurs in the course 
of an acute local affection, the treatment must of course be that which is 
proper for the concomitant disorder. When it depends on dentition, or 
on gastric or intestinal derangement induced by improper diet, the treat- 
ment is the same precisely as that recommended for laiyngismus stridulus 
dependent on the same causes. 

It may be stated that, as a general rule, all violent remedies, as bleed- 
ing, calomel, except in very minute doses as an alterative, drastic 
cathartics, and blisters, can scarcely fail to be injurious, unless manifestly 
necessary in the treatment of the concomitant affection. 

It is proper in almost all cases to combine with the treatment already 
recommended, the employment of antispasmodic remedies, particularly 
when the contractions persist after the removal of the primary disease. 

The best remedies of this class are the warm bath, used every day • 
belladonna ; conium ; the fluid extract of valerian ; assafoeticla, and cam- 
phor. The diet ought generally to be nutritious and strengthening, par- 
ticularly when the patient is weak and delicate. 

In conclusion we may state that the treatment should be very much 
the same as that proposed for laryngismus stridulus, and we therefore 
refer the reader to that subject for more detailed information. 

CASE BY DR. J. F. MEIGS. 

The subject of this case was a girl nine months old. The parents were 
healthy persons, but the mother, owing to some idiosyncrasy, had made 
but a poor nurse for the preceding child, and I had strongly advised her, 
therefore, at the birth of this one, to give it a wet-nurse. This was not 
done, however, and it was found necessary to feed the infant a great deal 
from its birth. During the early months of its life it had some slight 
attacks of disorder of the digestive system, but being taken to the country 
for several months in the summer, it there improved very much. On 
being brought back to town I saw it, and found it pretty well developed, 
but very pale, and, on the whole, delicate-looking. It was still nursed by 
the mother, but not to any very considerable extent, as it was obliged to 
be fed several times each day. The food consisted of different farina- 
ceous substances made with cow's milk. 

On the left forearm of the child there was situated a congenital aneurism 



CASE OF CONTRACTION. 533 

by anastomosis, which had grown, by the age of nine months, to be as 
large as a five-cent piece. It was deemed necessary to remove this tumor, 
and, accordingly, on the 11th of January, 1852, a surgeon tied it with a 
needle and double ligature. The child bore the operation very well, was 
soon quieted, and was cheerful and ate well until the evening of the 15th, 
when it was attacked with fever, which lasted all night, and was accom- 
panied with a good deal of cough and some gurgling in the fauces. On 
the following morning, at about 1% o'clock, it had a slight convulsive 
seizure, lasting a few moments, and marked by stiffening of the body, 
and a staring expression of the eyes. In the middle of the day, it was 
seized again, and during that and the next daj- (nth), up to 10 p.m., it 
had twenty-four convulsions. These lasted from three to eight minutes 
each; they were general, and consisted of flexions of the limbs, working 
of the face, and were attended with unconsciousness. There was no 
opisthotonos during the attacks, no extensions of the limbs, and no con- 
traction of the jaw. Between the seizures, the child nursed perfectly 
well, sucked the finger, had no stiffness of the lower jaw, and was per- 
fectly conscious. There was, during these two days, some fever, as the 
skin was too warm, and the pulse between 161 and 180. The respiration 
was more frequent than natural, there was a good deal of cough, some 
catarrhal rales in the chest, and also some gurgling in the fauces. The 
stools were scanty, pasty, and white. There was a well-marked but rather 
faint rash on the limbs and trunk, like erythema or mild scarlet fever, 
and the lymphatic glands on both sides of the lower jaw were somewhat 
swelled, and quite hard. The treatment directed was one-sixth of a grain 
of calomel every two hours ; two drops of solution of morphia with five of 
fluid extract of valerian, to be given also every two hours ; warm immer- 
sion baths, and mustard foot-baths. On the second day, blisters were 
applied behind the ears. 

On the 19th the child was better. There was no convulsion; she no- 
ticed well, smiled a little, nursed heartily, and took some arrowroot water. 

During all this time the tumor in the arm was not at all inflamed. It 
was neither red, sore to the touch, nor swelled. It was suppurating 
slightly. Under the idea that the convulsions might depend in part on 
the operation, and in order to promote suppuration, a warm poultice was 
kept constantly applied over the tumor. 

The child continued better, with the exception of slight angina and 
severe cough, until the morning of the 22d, when it waked early, crying 
violently as though in severe pain, and I found the fingers of both hands 
strongly flexed at the metacarpal articulation over the thumbs, which 
were themselves drawn into the palms of the hands. The phalanges, 
though bent, as just stated, at the metacarpal articulations, were stiffly 
extended at the phalangeal articulations, and at the same time separated 
from each other. The hands were flexed at the wrists. The toes were 
flexed, and the feet stiffly cramped at the ankles, and the insteps, as also 
the backs of the hands, looked swelled and cushiony. Any attempt to 
open the hands was painful and caused crying. The pulse was frequent 
and small, the skin pale, and very slightly too warm ; the intelligence was 



534 CASE OF CONTRACTION. 

perfect. The jaw was open, and the act of sucking was performed, but 
with some difficult}''. On the previous day the bowels had been opened 
three times, and on this day once ; the stools were scanty, pasty and 
white. At 9 a.m. I ordered two drops of solution of morphia, five of the 
fluid extract of valerian, and twenty of milk of assafoeticla, to be given 
every two hours. 

4 p.m. — Same state, except that the contraction is stronger. There is 
more heat of skin, much crying, and a restless, distressed motion of the 
head. At 4 i o'clock, two drops of laudanum were given with assafoeticla. 
A teaspoonful of the following mixture was ordered every hour : 

R.— Mass. Hydrarg., gr.iij. 

01. Kicini, ....... f^iij. 

Syr. Khei. Aromat., f gv. — M. 

10 p.m. — Has taken three doses of the mixture and had one large, 
whitish, pasty stool. Much easier. Has slept a good deal. Contractions 
not so strong, as the hands can be opened more easily and with very little 
pain. Skin soft, of natural temperature, and moist. Ordered one or two 
more doses of the mixture, and a repetition of the laudanum and assa- 
fcetida, in case of restlessness. During all this time the tumor has not 
separated. A process of ulceration is going on around the ligatures, but 
there is no inflammation of any consequence ; the arm is not swelled, and 
there is neither redness nor soreness to the touch. 

January 30th. — The contracture diminished very much for two days, 
and then returned, so that during the 2tth, and 28th, and 29th, it was 
very marked, the forearms being flexed on the arms, and the hands 
strongly flexed on the forearms. The feet also were very stiff, and 
strongly flexed. The head was occasionally but not constantly retracted 
upon the trunk. The child evidently suffered very much, as it cried con- 
stantly and was very restless, except when under the influence of anodynes 
or antispasmodics. The bowels are sluggish, but have been kept open 
bjr the oil and rhubarb mixture. The dejections were generally whitish 
and pasty, but occasionally there was a healthy yellow stool. On the 28th 
the following- mixture was ordered : 



R.— Ext. Valerian. Fluid., 



*$• 



Sp. .zEtheris Comp., ..... f gss. 

Liq. Morph. Sulph., ..... gtt. lx. 

Syr. Tolutan., f^vj. 

Aquae, fgij.— M. 

A teaspoonful to be given every hour or two, when there is much suffering or rest- 
lessness. 

On the evening of the 29th the ligatures were removed, as thej^had be- 
come entirely loose, though without cutting off the tumor. The diseased 
point was not much inflamed, nor was it very tender. 

The child is still nursed and fed. Since the 29th it has had goat's in- 
stead of cow's milk. On the evening of the 30th the patient was more 



CASE OF CONTRACTION. 535 

tranquil, the expression was more placid and open, and the contracture 
not quite so strong. 

Up to February Tth, there was no decided change in the symptoms. 
They continued quite as severe as before. The dyspeptic symptoms, the 
torpid state of the bowels, the want of appetite, and the white, pasty state 
of the evacuations were never relieved, except momentarily, b}< means of 
cathartics. On the tth a wet-nurse was procured, but only after the most 
persevering and urgent solicitation and argument on our part, I having 
long been convinced that the cause of the contracture lay in the disor- 
dered state of the digestive functions, produced and kept up by artificial 
diet, and perhaps by an unhealthy state of the mother's milk. The pa- 
rents, however, had alwa}'s thought that the operation had been the cause 
of the convulsive disease, and for a length of time would not consent to 
a wet-nurse. 

After the child had been suckled by the wet nurse for two cla}^, the 
stools, which, since the beginning of the sickness, now twenty-three da} r s, 
and to a greater or less extent since birth, had been very unhealthy, be- 
came yellow, homogeneous, and natural in character ; while the bowels, 
instead of being obstinately constipated, so as to require large doses of 
cathartic medicine, were moved spontaneously two or three times a day. 

On the 10th we noticed strong divergent strabismus, and the child 
looked very badly. The left leg was drawn up, whilst the right was stiff- 
ened. The left arm was more used than the right, the left hand being 
carried often to the mouth, while this was never done with the right. It 
was difficult to measure the degree of the intelligence, but the child occa- 
sionally looked at and evidently noticed objects, but during most of the 
time it was dull and inattentive. 

On the 13th there was an evident improvement, the previous night hav- 
ing been very good. The face was improved in color and expression, and 
was not quite so thin. The contraction was about the same. 

14th. — Some diminution of the contraction, the forearm being a little 
extended upon the arm, and the wrists, though still very rigid, not quite 
so much drawn. The child looks better ; she nurses a great deal, taking 
all that the mother, and most also of what the wet-nurse, a hearty woman, 
has. 

Februar}^ 20th. — Doing very well up to last night, when she became 
more restless, cried a great deal, rolled the head on the pillow, and had 
slight retractions of the whole trunk of the body. Occasionally she ceased 
to cry, scarcely breathed, and the eyes were rolled upwards and fixed for 
several seconds. She looked pale and pinched again, and refused to nurse. 
Had one whitish, curdy stool. 

21st. — Better ; more quiet; nurses well. The boring with the head has 
ceased, and also the retractions of the trunk. One kealtlry stool. 

22d. — Much better ; nurses well ; one healthy stool. The contraction 
of the right arm is yielding, and that of the forearm on the arm is gone 
on both sides. The left wrist is straight ; the right one is yielding very 
much, though it is still somewhat bent. The fingers of the right hand, 
though still bent, have relaxed very much; those of the left hand are still 



536 CASE OF CONTRACTION. 

veiy much bent, but are less rigid than before. The integument of the palms 
of both hands has become, in the flexures, whitish, soft, moist, mucous- 
like, and has an offensive odor. To-day and yesterday the child uses the 
arms, touches, and reaches out for articles ; she is much more intelligent, 
and looks at and observes objects ; she now holds her head up, and likes 
to be carried about sitting up in the arms of the nurse, which before she 
could not do at all. She is gaining flesh; the color of the surface is im- 
proving; the ears have become pink and pretty. 

A fresh assafcetida plaster was applied upon the back yesterdaj^. 
March 1st. — Continues to do well. The right hand is to-day almost 
natural, being opened and shut, and used to grasp with, though it still 
looks a little stiff. Left hand much better ; she opens and shuts the fore- 
finger, and grasps and holds to} T s with it, but the other fingers are still 
much contracted. The movements of the arms are quite easy and natural. 
There is no bending of the hands at the wrists, except, perhaps, very 
slightly in the left extremity. The feet are natural, except a slight stiff- 
ness. She now nurses very well, and is growing fat. She is larger, in 
fact, than before the sickness. The intelligence is improving rapidly, as 
she notices, smiles occasional^, and distinguishes, her attendants think, 
between persons. The bowels are regular without medicine. She has 
taken no remedy of any kind for three da} T s past. 

March 11th. — Almost entirely recovered. There is still a slight but 
only very slight flexion of the fingers of the left hand. General health 
excellent. 

March 29th. — The patient is now perfectly well, except that she uses 
the forefinger of either hand rather better than all together, so that in 
grasping and holding an object, she is more apt to seize it with the fore- 
finger than with all. Still she can and does grasp with all, when the ob- 
ject is large, and no one, unless very observant, would notice the pecu- 
liarity just described. Embonpoint very good ; complexion clear and 
health}' ; sleep sound ; bowels in excellent condition. Intelligence perfect ; 
smiles and laughs a great deal, and distinguishes between persons ; takes 
a great deal of notice. She is about equal in intelligence to a child of 
eight months old. Does not attempt to speak. 

April 10th, 1852. — I was sent for to-daj^. The child had not been 
well for three days, having had three or four thin and greenish stools a 
day, with whitish specks in them. She was fretful and did not sleep well, 
and had a good deal of loose catarrhal cough and some acceleration of 
the breathing. I found her in the morning, after a restless night, quite 
feverish, hot and dry, with frequent respiration, and with some catarrhal 
wheezing in the chest. She had coughed a good deal, and her mother 
had found her hands showing some signs of spasm, the forefingers being 
extended as though pointing, and separated from the other fingers, which 
were flexed, with the thumbs also, into the palms of the hands. 

There is some degree of laryngismus, as on waking from sleep the 
breathing is labored, difficult, partially suspended, and accompanied with 
a slight crowing, or rather choking sound, while at the same time the face 
becomes pale and the mouth bluish. Bowels open three times yesterday, 



CASE OF CONTRACTION. 537 

the stools being mucous, greenish, and containing small lumps of undi- 
gested caseine. 

Ordered a quarter of a grain of mercury with chalk diffused in a tea- 
spoonful of syrup of jalap, to be given every two hours. 

At 1 p.m. there was a slight general spasm, with stiffening of the limbs 
and retraction of the head, lasting, however, only a few moments. This 
occurred again in the afternoon. The dose of the mercury and jalap was 
reduced one-half in the middle of the day, as the quantity first ordered 
was found to cause sickness and vomiting. 

Evening. — Rather better. !S T o fever ; some moisture of the skin ; spasm 
of the hands veiy much relaxed. The diminished dose of mercury and 
jalap was well borne. 

11th. — Rather better. Some fever still, with cough, gurgling in the 
throat, and distinct enlargement and hardening of the lymphatic glands 
at the angles of the jaw on both sides. There is still some contraction 
of the hands. Bowels open freely twice last night, and the stools better, 
being of a pale 3 T ellow color, and more homogeneous. The jalap and 
mercury to be suspended. 

In the course of the cla}^ there were two slight general spasms, with 
laryngismus. The latter occurred several times during the waking state, 
but was not severe. Ordered three drops of syrup of ipecac, ^vith four 
of sweet spirits of nitre, to be given every two hours. 

12th. — Much better. Contraction of hands almost gone; very slight 
feverishness ; cough less frequent and looser ; respiration easy. No spasm 
to-day. Stools more healthy, yellow, homogeneous, and of natural 
quantity. 

13th. — Continues better. Contraction slight. Cough diminishing very 
much. 

14th. — Rather pale, dull, and languid. Has had several attacks of 
laryngismus, one of which was quite severe, being attended with deep 
blueness about the mouth, and some of the face also. Does not nurse so 
well as formerly. The hands exhibit decided flexion of the third, fourth, 
and fifth fingers at the metacarpophalangeal articulation, with stiffened 
extension of the other phalangeal articulations. Thumbs slightly drawn 
into the palms, and the forefingers rather extended. Bowels natural. Or- 
dered fifteen drops of brandy, and a very small pinch of the Quevenne's 
metallic iron in powder, three times a da}^. 

15th. — Condition about the same. On the 22d of March, the first wet- 
nurse, under whose charge the child had improved so rapidly, was changed, 
on account of some objection to her personal appearance, and another 
one procured in her place. This one was a healthy-looking woman, with 
milk enough, but she was red-haired, irritable, and excessively high- 
tempered, and the child has been losing ground ever since her arrival. 
Under the idea that her milk did not suit the child, a third nurse was by 
my advice, obtained to-day (15th), a calm, placid, fat, and comfortable- 
looking woman, with an abundant supply of milk of ten months old. 

lTth. — The child has improved very much. She is fatter already, has 
a contented, tranquil expression, takes more than she did from the pre- 



538 TETANUS NASCENTIUM. 

vious nurse, and rejects much less of the milk. The stools are now regular, 
occurring twice daily without aid, and of a natural appearance. The sleep 
of the child is better now than it has been at any time since the first wet- 
nurse was dismissed. The attacks of laiyngismus are already much less 
frequent, and less severe. The hands are very nearly in a natural condi- 
tion. The child is less nervous, not starting now as formerly at sounds. 

To continue the brandy and iron. 

From this period the child continued to improve regularly in health. 
She was removed to the country during the summer months, and when 
brought back in the autumn was entirety well, with the exception that 
she was less forward in walking than most children, but not more so than 
might have been expected in one who had been dangerously ill for so 
long a time. Her intelligence was good in all respects. 

February 5th, 1853. — We have seen this child to-da3 r , and find her in 
very good health, except that she is rather smaller in size than is usual 
at her present age. She has been weaned now for about six weeks, and 
eats heartily and digests well most ordinary food, as milk, meat, potatoes, 
&c. The weaning was borne, very well, except that the appetite was 
rather deficient and capricious, for about a week after, the departure of 
the nurse. She can stand up when placed in the erect position, and can 
walk feeMy when well supported, but not alone, nor can she rise up from a 
sitting posture. Her intelligence is, in all respects, perfect, but she does 
not talk as yet. There is no vestige of her former spasmodic symptoms, 
when she is in good health ; but any little turn of sickness reproduces 
some contraction of one leg, and a slight flexion of the hands. 

Some months after this, the child was unfortunately seized with hooping- 
cough. She did well for several weeks, but one day, being seized with 
a fit of coughing while seated upon the floor playing, died instantly, 
doubtless from asphyxia, caused by complete closure of the glottis by 
spasm. This is the only case of hooping-cough that we have ever 
known to prove suddenly fatal in this way. There is every reason to 
suppose that the fatal suspension of respiration was caused by the un- 
natural excitability of the sphincter muscle of the glottis, left by the 
previous attack of laiyngismus stridulus. 



AETICLE IX. 

TETANUS NASCENTIUM. 

Definition ; Synonymes ; Period of Occurrence ; Frequency. — Tet- 
anus nascentium is a most fatal affection, occurring principally during 
the first two weeks after birth, usually running an acute course, and char- 
acterized by a more or less general tonic contraction of the voluntary 
muscles, with parox3 T smal exacerbations, and usually without any period 
of complete relaxation until the close of the malaclr. 

From this definition it will be seen that the affection does not differ in 



GENERAL CAUSES. 539 

its essential nature from tetanus as it occurs in adults ; though there are 
so many peculiarities in its causes and symptoms as to demand a special 
discussion. This disease has also been described under the names of tris- 
mus nascentium or neonatorum, in accordance with the prominence and 
frequency of contraction of the muscles of the lower jaw : but as the spasm 
is rarely limited to these muscles, but usually involves the other muscles 
of the face and those of the extremities, the more comprehensive name of 
tetanus seems more appropriate. It most frequently makes its appear- 
ance between the third and tenth days after birth, although there are 
cases on record in which it set in fifteen hours after birth (West), and 
others where it did not manifest itself until the twelfth or fifteenth day. 

Causes. — The causes which have been assigned for the production of 
tetanus nascentium are very numerous ; they may, however, be generally 
divided into the groups of general and local. Among the local causes, 
the various morbid conditions of the umbilicus and umbilical vessels hold 
the most prominent place. These are, however, far from being constantly 
present, and yet the weight of evidence is at present in favor of regard- 
ing diseases of the umbilicus, and more especially of the umbilical arteries, 
as occasional causes of tetanus nascentium. 

In other cases, the disease has been attributed to some blow or acci- 
dental injury which the infant had received. It is, however, still "a vexed 
question as to how much influence should be ascribed to these purely me- 
chanical impressions in the production of this affection. One of the most 
powerful efforts jet made to establish their importance was by Dr. Marion 
Sims, 1 who published a series of articles to prove that "trismus nascentium 
is a disease of centric origin, depending on a mechanical pressure exerted 
on the medulla oblongata, and its nerves ; and that this pressure is the 
result, most generally, of an inward displacement of the occipital bone." 
This displacement is physiological during the parturient state, but its 
persistence after birth is dependent, according to his theory, chiefly upon 
the improper position in which infants are allowed to lie, resting upon 
their occiput for daj x s together. 

Further experience, however, has not confirmed this view, nor justified 
the admission of injury to the cranial bones into the list of common causes ; 
and yet there are a few cases on record in which tetanus undoubtedly ap- 
pears to have been developed from this source. 

General Causes. — Vicissitudes of temperature appear to favor the 
development of tetanus, since it is frequent in many countries where a 
high temperature during the day is succeeded by great cold during the 
night. In the same way, exposure of the infant to wet and cold, as by 
putting damp clothes upon it, may be productive of the disease. The 
most frequent and well-established cause of tetanus nascentium, however, 
is a vitiated state of the atmosphere ; whether engendered by a filthy 
condition of the bedding or house; or by imperfect ventilation ; and it is 
to this that we must attribute the frequency of the affection in such dis- 

1 Amer. Jour, of Med. Sci., April, 1846, p. 363; July, 1818, p. 59; and October, 
1848, p. 355. 



540 TETANUS NASCENTIUM. 

similar localities, as the Western Hebrides, Iceland and the neighboring 
islands, and some of the Southern States of America, where it was for- 
merly not at all nnusual for 50 per cent, of all infants born to perish 
during the first two weeks from this cause alone. It was formerly sup- 
posed that certain localities, pre-eminent among which are those just 
mentioned, were peculiarly favorable to the development of this disease, 
but it is probable that no predisposition exists excepting the fluctuations 
of the climate and the filthy habits of the people. 

The very great importance of filth and deficient ventilation as a cause 
of tetanus nascentium is, however, most forcibly shown by the great re- 
duction in the frequency of this disease in large Lying-in Asj^lums, effected 
b} T the introduction of more thorough ventilation and a greater regard to 
cleanliness. This was conclusively demonstrated in the Dublin Lying-in 
Asj'lum towards the close of the last century. Previously to the year 
1782, of 11,650 infants born alive in the as\4uni, 2944, or almost one- 
sixth, had died within the first fortnight, and in almost every one of these 
the cause of death was tetanus nascentium. During the next seven years, 
after Dr. Clarke had simply introduced a much more complete sj^stem of 
ventilation in the wards, of 8033 children born, only 419 in all died, or 
about 1 in 19, or 51th per cent. 

Our comparative immunity in this part of America, even among the 
poor in our cities, is probably due to the greater degree of cleanliness in 
their houses, and to the improved construction of our hospitals and asy- 
lums. In ]S~ew York, however, according to Dr. Smith, 1 there are more 
deaths from tetanus during the first year of life than at all other ages 
together. 

The mortality returns of this city indicate that tetanus, although com- 
paratively frequent among infants, is much less so than in New York. 

Thus during the 9 years, from 1860 to 1868 inclusive, the returns show 
a total mortality (less still-born), at all ages, of 121,563, and under 1 year 
of 36,165. During this period there were 233 deaths from tetanus at all 
ages; 61 of which were during the first } T ear of life, and 151 after that 
age. Thus the proportion of deaths from tetanus to those from all causes 
was, after the age of one year as 1 to 598, and during the first year of 
life, as 1 to 602. 

During this same period, the number of births in Philadelphia, amounted 
to 146,895. 

Pathological Appearances. — We have alread}^ alluded to the morbid 
conditions of the umbilical vessels or umbilicus occasionally found in 
tetanus nascentium ; it is evident, however, that if these lesions have any 
connection with the disease, they merely act as exciting causes. 

The only characteristic lesions of this affection are presented by the 
nervous system. 

The brain and its meninges are frequently found intensely congested, 
though this is not so uniformly present as a similar condition of the spinal 
cord ; according to numerous observers, however, it is more frequently 

1 Amer. Jour. Med. Sci., July and October, 1865; and op. cit., p. 168. 



PATHOLOGICAL APPEARANCES. 541 

present than absent. In some cases, this congestion has led to an actual 
effusion of blood, either between the skull and dura mater, into the arach- 
noid cavity, or into the ventricles. In some cases, instead of hemorrhage, 
there has been found serous effusion into the ventricles or into the sub- 
arachnoid space, accompanied with a diminution of consistence of the 
cerebral substance, as reported by Matuszynski. 

The morbid appearances found in connection with the spinal cord are 
the same in character as the above, but more constant and even more 
marked. The vessels of the spinal meninges and of the substance of the 
cord are intensely congested, and there is frequently effusion of blood 
into the cavity of the arachnoid. 

The value of these appearances was formerly under-estimated from a sus- 
picion that they might be partly, at least, due to the mere gravitation of the 
blood after death. This suspicion has, however, been entirely removed 
by the observations of Weber, of Kiel, and Finckh, of Stuttgardt, who 
placed the bodies of infants dying with tetanus in various positions be- 
fore examining them, and yet invariably found the above-mentioned con- 
ditions. 

There is, however, a further source of doubt as to the significance of 
these lesions. We have already seen, in speaking of eclampsia, an affec- 
tion in which no appreciable material lesion has as yet been detected, 
that, in a certain proportion of cases, congestion, serous effusion, or- actual 
hemorrhage might be present not as causes but as effects, and due merely 
to the intense venous engorgement caused by the embarrassment of the 
respiration and venous circulation during the convulsion. It is, indeed, 
it seems to us, highly probable that a similar interpretation may be placed, 
in many cases at least, upon the morbid appearances above mentioned 
as being found after death from tetanus nascentium. 

We have thus enumerated the lesions of the nervous system which are 
readily discoverable in many fatal cases of tetanus ; and yet these lesions 
are, it will be observed, almost without exception concerned merely with 
the vascular supply of the brain and spinal cord, and we are as yet with- 
out an}^ accurate investigations into the condition of the nervous tissue 
itself. Within the past few years, the wonderful advances of micro- 
scopical science, as applied to pathological anatomy, have revealed struc- 
tural changes in the nervous system in connection with more than one 
disease, whose pathology has heretofore been utterly obscure, and it is 
not too much to hope that at no distant period the question of the pres- 
ence of any definite structural change in the brain or spinal cord in cases 
of tetanus nascentium will be positively settled. In connection with this 
suggestion, especially in consideration of the analogy between this dis- 
ease and tetanus in the adult, we append the results of the investigations 
of Rokitansky and Demme upon the microscopical appearances in the 
spinal cord in fatal cases of this latter affection. 1 

1. The constant anatomical character of tetanus appears to be prolifera- 

1 Schmidt's Jahrb., vol. iii (in New Syd. Soc. Year-Book, 1864, p. 232). 



542 TETANUS NASCENTIUM. 

tion of the connective tissue (of the cord) ; the most striking peculiarity 
of this lesion is the extent over which it is found. 

2. The product is a viscous mass, abounding in nuclei ; it remains at 
this stage of development in both acute and chronic cases, never progress- 
ing to the formation of fibres. 

3. This change is found almost exclusively in the white medullary sub- 
stance ; the gray matter seems to suffer only secondarily, and then from 
compression rather than interstitial deposit. 

4. The proliferation is not alwaj^s followed by corresponding swelling 
of the white matter; it can often be recognized only by means of the 
microscope. 

5. It w r as principally found in the medulla oblongata, the crura cerebri, 
the inferior peduncles of the cerebellum, and in the greater part of the 
spinal cord. 

6. This lesion of the connective tissue appears to be due to long-con- 
tinued or repeated congestions. 

7. The period at which it occurs, probably varies in different cases. 
These observations, which were originally published about 1860, have 

been confirmed in all essential particulars by Wagner (Syd. Soc. Year- 
Book, 1862, p. 219); and still more lately by J. Lockhart Clarke, who 
published in the Med. Chir. Trans., vol. xlviii, the results of the micro- 
scopic examination of the spinal cord in six cases of tetanus, in all of 
which structural lesions were discovered; and by Dr. Dickinson {Med. 
Chir. Trans., vol. li, p. 265). 

Symptoms. — There are rarely any premonitory symptoms of the attack, 
but the onset and development of the disease are usually gradual. The 
earliest S3 T mptom noticed is, in most cases, difficulty in nursing; the in- 
fant appearing anxious to nurse and eagerly pressing its mouth against 
the nipple, but being unable to fully take it into the mouth or to suck, 
from a rigid condition of the masseter muscles. At the same time it 
utters a whimpering, whining, unnatural cry. 

The tonic muscular contraction very rarely remains limited to the 
m asset ers, but soon invades the other muscles of the face, and those of 
the trunk and extremities. 

The expression of the face thus produced is indicative of great suffer- 
■ ing; though it is impossible to say how truly this represents the sensa- 
tions of the patient. 

The face is drawn into wrinkles and furrows, and has a strange appear- 
ance of age. The condition of the mouth, however, is most characteristic ; 
the jaws are firmly fixed, the lips slightly separated and pressed firmly 
against the gums, and the angles of the mouth drawn backwards and 
downwards, in the well-known risns sardonicus. 

During this time, the other voluntary muscles gradually become rigid. 
At first, their contraction can be overcome by the use of a moderate de- 
gree of force, but in the course of twelve or twenty-four hours, the period 
of maximum rigidity is attained. The head is drawn backwards, and 
firmly fixed; the arms are flexed, and the hands clenched, with the thumbs 
drawn across the palms. The thighs may be flexed upon the pelvis, or 



SYMPTOMS — PROGNOSIS. 543 

the legs crossed ; the great toes are usually adducted and separated from 
the rest, which are flexed. 

The contraction of the dorsal muscles frequently produces opisthotonos ; 
and the entire body is at times rendered so rigid that it can be raised, 
without bending, by placing a hand under the heels and head. This ex- 
treme degree of spasm of all the voluntary muscles may never be devel- 
oped in some cases ; or, when present, it often is not persistent. When 
the infant is quiet or sleeping, there is usually a certain degree of relaxa- 
tion. It is a marked peculiarity of the affection, however, that exacer- 
bations of the tonic spasm are produced by the slightest exciting causes, 
as an effort at deglutition, a sudden noise, a puff' of air, the most delicate 
touch, or even the alighting of a fly upon the surface. During these par- 
oxysms or clonic spasms, the muscular rigidity and contraction attain 
their greatest height, and produce the most painful distortion of the face 
and limbs. The fit, according to West, may be ushered in b} T a screech. 
During its continuance, there is serious interruption of respiration and 
circulation ; the surface becomes livid, and epistaxis may occur. It is 
during this condition, too, that hemorrhages into the brain or spinal cord, 
or their meninges, may result. 

These paroxj^sms recur at irregular intervals, but usually, in fatal cases, 
occur with increasing frequency until either the child expires suddenly 
during one of the fits, or passes into a state of coma. 

The pulse does not present any characteristic change ; in some cases it 
has been found accelerated, but in others has continued normal, or has 
even fallen below the healthy rate. 

The condition of the bowels is not uniform. Diarrhoea is frequently 
present, but is probably clue to irritation of the bowels from the irritating 
nature of the ingesta, or to some accidental cause ; particularly as the 
bowels are occasionally constipated in well-marked cases. 

The appetite generally appears to continue, but we have already al- 
luded to the fact that any attempts to feed the child bring on violent spasms, 
which expel the greater part of the food taken into the mouth. Owing 
principally to this obstacle to the nourishment of the infant, the emacia- 
tion is more rapid and marked in this than in almost any other affection 
of infancy. 

The state of the pupils in tetanus nascentium has not been noted with 
sufficient frequency or accuracy to allow any deductions to be drawn 
with regard to it. Smith has seen the pupils contracted in the last stage 
of the disease. 

Prognosis. — The majority of authors state that they have never met 
with a case of recovery from fully established tetanus nascentium. 

Dr. Smith has, however, collected 8 cases of recovery, in the histories 
of which he calls attention to two important peculiarities ; that the chil- 
dren were all about a week old when the initiatory symptoms appeared, 
and that there were fluctuations in the sj'mptoms of the disease. The 
only circumstances, then, which would lead us to form a less gloomy 
prognosis than usual, are the late appearance of the disease, and the 
mildness and intermitting character of the symptoms. 



544 TETANUS NASCENTIUM. 

The diagnosis of this affection presents no difficulties, being readily 
made by attention to the persistent muscular contraction, the inability to 
suck or to take food, and the exacerbations which are produced by the 
slightest causes. 

Duration. — In fatal cases, the duration rarely exceeds forty-eight or 
seventy-two hours, and death frequently occurs during the first day. 
There are instances, however, in which its course has been prolonged to 
the sixth, or even the ninth day ; and Smith refers to two remarkable fatal 
cases, recorded by Underwood and Elsasser, in one of which the duration 
was six weeks, and in the other thirty-one days. 

Dr. Wells has reported {Brit. Med. Jour., Dec. 21st, 1861) the follow- 
ing case of chronic trismus : The child died at the age of one year — having 
been, from its birth, in a state of tonic spasm, or trismus ; it was alv^s 
restless, and appeared ill nourished, though there was no reason for this. 
All treatment was unavailing. It was suggested that the child's state 
might proceed from irritation due to the mother's milk; and the child was 
weaned, but without benefit. At the post-mortem examination, there was 
found a considerable opalescent effusion over the surface of the brain ; 
the cerebellum was harder than usual, and on being cut into presented a 
homogeneous appearance. The arbor vitse was entirely wanting. 

In favorable cases, the duration varies from a few days to one month, 
or even more. 

In the 8 favorable cases collected by Smith, the duration was, in 1 case, 
two days ; in 1, a few days ; in 1, fourteen clays ; in 2, fifteen claj^s ; in 1, 
twenty-eight days; in 1, thirty-one days; and in the remaining case, 
about five weeks. 

Prevention and Treatment. — It is fortunate that we can by wise 
hygienic measures do much to prevent the occurrence of a disease of 
such fatality, and in which, when once fully developed, treatment is so 
unavailing. We have already alluded to the vast diminution in the num- 
ber of deaths from this disease, which followed the introduction of free 
ventilation and cleanliness into the wards of the Dublin Lying-in Hos- 
pital. ^Nor are the good effects of this practice limited to public institu- 
tions, but it has been found that wherever the disease has prevailed to any 
extent, as on the Southern plantations, its progress can be arrested by in- 
sisting upon the observance of cleanliness in bedding and clothing, of 
mother and child ; by cleaning, disinfecting, and freely ventilating the 
houses ; by care in dressing the umbilical cord ; and, finally, by attention 
to the food of the infant, and the condition of its bowels. 

Even when the disease has made its appearance, these same measures 
should be carried out with equal care, since, by removing all possible 
causes, so far as we are acquainted with them, we may mitigate the sever- 
ity of the attack. 

In addition to the removal of the causes, the strictest quiet should be 
enjoined, and all care emplo} 7 ed to avoid exciting the violent parox3 T sms, 
which are so readily induced. 

It would be well, in addition, to examine the occipital region, to dis- 
cover if the occipital bone be unnaturally depressed, since in one or two 



PREVENTION AND TREATMENT. 545 

eases this has appeared to act as the exciting cause of the attack. If 
such depression be found, the position of the child should be varied by 
placing it on its side, in accordance with the recommendation of Dr. 
Sims. 

The application of leeches to the nape of the neck or along the spine, 
appears indicated in the early stage of the disease. Dr. West advises the 
practice, though he has had no experience in its use. Collins, however, 
states he has tried frequent leeching along the spinal column, without the 
least benefit. 

Purgatives are only useful to the extent of maintaining regular action 
of the bowels. 

The remedies which have been most highly recommended as directly 
curative, are ether and chloroform, and various narcotics and antispas- 
modics, as opium, belladonna, aconite, cannabis Indica, conium, woorara, 
tobacco, and assafcetida. 

Anaesthetics have been employed frequently in tetanus of the adult, 
and occasionally in the affection under discussion. Despite, however, 
the great expectations which were entertained in regard to their utility, 
their action cannot be considered directly curative. They relieve suffer- 
ing, however, and by temporarily aiding the spasmodic contraction of 
the muscles, enable us to administer food or remedies, and thus prolong 
life, and give time for other agents to act. " So long, therefore, as the 
patient is able to take food and to obtain periods of comparative quiet, 
the use of anaesthetic inhalations is not desirable. Great advantages 
may, however, be obtained from them if he be unable to open the jaw 
sufficiently to permit of taking food, or if the tetanic spasms are without 
remission. Ether appears to have stronger facts in its recommendation 
than chloroform." (J. Hughlings Jackson and Hutchinson's Report on 
Tetanus, Med. Times and Gaz., April 6th, 1861.) 

The evidence in regard to the superior efficacy of any particular narcotic, 
is highly conflicting. Opium has, until recently, been the one usually re- 
lied upon, and several recoveries have occurred under its use. 

Of late years, however,' various other narcotics have been employed, 
especially in traumatic tetanus in the adult. Thus belladonna and its 
alkaloid atropia have been used, the latter hypodermically, with occasional 
good results. If the sulphate of atropia is used hypodermically in in- 
fants, the first dose should not exceed the ^ho^ or ilo^ °f a grain, so 
that its effects may be tested carefully. One-half grain of the salt may 
be dissolved in a fluid-ounce of water, and four to six drops injected 
under the skin along the spine. 

The various preparations of cannabis Indica have also been extensively 
used. Dr. Gaillard reports two cases of recovery from tetanus nascentium 
under this treatment; in one of which the infant, aged eight clays, took as 
much as f^ss of tincture of cannabis Indica in a single day — being equiva- 
lent to about eleven grains of the pure extract. This quantity, however, 
appears excessive. 

Woorara has been given in twenty-two cases, according to Demme, 
with eight cures. It has been recommended by Harley, Spencer Wells, 

35 



546 CHOREA. 

Broca, Yella, Chassaignac, and others. The close in which this poisonous 
substance has been given, is from one-eighth to one-half grain to an adult. 
The great objection, however, to both this remecty and cannabis Indica, 
is the great want of uniformity in the strength of their preparations, which 
necessitates the utmost caution in their use. 

More recently still, numerous cases of tetanus in the adult have been 
treated with the various preparations of conium, and with its alkaloid 
conia, and the results have been of a decidedly encouraging character. 

Among the antispasmodics most frequently used, are assafcetida and 
tobacco, either given internally or by enema, or added to a warm bath. 
There is no very positive evidence, however, of their efficiency in this 
disease. 

Baths, either of warm water or vapor, should be repeatedly given ; they 
tend to act favorably as sedatives, by relaxing the muscular spasm, and, 
in addition, excite the action of the skin. 

The free use of large doses of quinine, usually in combination with one 
of the narcotics above mentioned, appears to be serviceable in traumatic 
tetanus, by reducing the frequency of the pulse and mitigating the ten- 
dency to spasm, so that the induction of cinchonism in tetanus nascen- 
tium is a measure worthy of a fair trial. 

The application of ice to the spine has been highly recommended in 
tetanus in adults, and is reported to have been used with success in 
several cases. The condition of the bloodvessels of the cord and its 
membranes, in fatal cases of tetanus nascentium, would certainty appear 
to indicate its use in this affection also. 

Whichever of the above plans of treatment may be adopted, it must 
never be forgotten that one of the principal clangers and most frequent 
causes of death in this disease, is the obstacle offered to the nourishment 
of the infant. We must pay attention, therefore, to the administration of 
milk, meat-broths, and alcoholic stimuli in small quantities, but frequently 
repeated; and if the rigidity of the jaw and the occurrence of spasms 
upon every attempt at deglutition, prevent the child from taking food, 
we should have recourse to anaesthetics to relax the spasmodic muscular 
contraction, and enable us to get nourishment into the stomach. 



AETICLE X. 

CHOREA. 

Synonymes; Frequency Chorea is a non-febrile, con- 
vulsive disease, characterized by irregular and imperfectly co-ordinated, 
but not completely involuntaiy contractions, of different parts of the mus- 
cular s3 T stem, and particularly of that of the extremities. 

It is called also St. Yitus's dance, chorea sancti viti, choreomania, 
epilepsia saltatoria, and by various other titles. 



PREDISPOSING CAUSES. 547 

"Without being very rare, chorea is certainly not of very frequent occur- 
rence. M. Rnfz states (Diet, de 3Ied., t. vii, p. 544), that of 32,976 chil- 
dren admitted into the Children's Hospital of Paris in ten years, only 189 
were affected with chorea, or 1 in 317. We have met with bnt nine cases 
in private practice in the course of over twenty years' experience. 

Predisposing Causes. — Age. — Chorea very rarely occurs during in- 
fancy. According to M. Rufz, it is seldom met with between one and six 
years of age, since of 189 cases, in only 10 did it occur within that period; 
while between six and ten years of age it is much more common (61 in 
189 cases); and between ten and fifteen years still more so (118 in 189). 

M. See, in a valuable essay on chorea (Mem. de VAcad. Nat. de Mede- 
cine. t. xv, p. 373), and the relations of rheumatism and diseases of the 
heart, with nervous and convulsive diseases, states (page 448), that of 
531 cases of chorea treated in the Children's Hospital at Paris, during a 
period of twenty-two years, 28 were under six years, 218 between six and 
ten years, and 235 between six and fifteen j-ears of age. M. See con- 
cludes, after carefully sifting the facts, that the true maximum of fre- 
quency is comprised between six and eleven years of age, and that it 
corresponds especially to the tenth year. Under six jesus of age it be- 
comes more and more rare as we approach the moment of birth. MM. 
Simon and Constant, howeA T er, met with it in nursing children of twelve, 
six, and four months of age. 

The statistics furnished by Hillier 1 confirm these statements in every 
detail. Thus, of 422 cases treated as out-patients at the Children's Hos- 
pital in London (where no patients over twelve years are received), the 
numbers at different ao-es were as follows : 



Prom 3 months 


to 6 


months, 


3 


Prom 


6 


y 


ears 


to 7 


years, 


. 48 


(< 


6 " 


12 


a 


5 


u 


7 




u 


8 


u 


51 


(< 


12 


18 


a 


2 


(« 


8 




a 


9 


a 


. 58 


(< 


18 


2 


years, 


4 


u 


9 




a 


10 


u 


80 


(< 


2 years 


3 


u 


6 


a 


10 




a 


12 


it 


104 


a 

a 


3 « 

4 " 


4 

5 


11 

u 


11 

20 














422 


a 


5 » 


6 


it 


30 

















Sex. — It is much more frequent in girls than boys. Of the 531 eases 
cited by M. See, 393 occurred in girls, and only 138 in boys. This is the 
same result as that attained, M. See remarks, by Reeves, Good, &c, — 131 
girls in 186 cases. 

This excess of females over males obtains in chorea of every grade, 
from the mildest to the most rapidly fatal cases. 

Rapid growth and the second dentition probably act, in a considerable 
degree, as predisposing causes of the disease. Particular attention is 
drawn to these conditions by MM. Rilliet and Barthez, and the precise 
age at which it is most frequent (between six and eleven years), would 
seem to show that they exert a very positive influence. The general de- 
terioration of the health, resulting in ansemia, and the exaggerated nervous 

1 Diseases of Children (Amer. ed., 1868, p. 234). 



548 CHOREA. 

susceptibility, so often observed at these periods, are probably the imme- 
diate causes of the frequency of the disease at this epoch of life. 

An altered and anaemic state of the blood has also been supposed, as 
by Ogle 1 and Barnes, 2 to be the efficient and exciting cause of the affec- 
tion. Rilliet and Barthez, 3 also, when speaking of rheumatism as a cause 
of chorea, say that, " while admitting the existence of rheumatic chorea, 
it must not be forgotten that the disease is frequently of a different 
nature, and that we meet in authors with incontestable examples of 
chorea consecutive to chronic diseases that have produced a debilitated 
condition of the economy, ... as chlorosis, anaemia, and tuberculosis." 

Constitution does not seem to exert much influence in its production, 
though it is generally thought to be most apt to occur in children of 
delicate, excitable, and nervous temperament. The belief in hereditary 
predisposition seems to be unfounded save in rare cases. The disease 
appears to commence more frequently in summer than in winter, and yet 
it is scarcely known in tropical climates. 

Rheumatism, however, is unquestionably the condition in connection 
with which chorea occurs far more frequently than with an} 7 other, or 
perhaps than with all others conjoined. The evidence of all observers of 
experience is unanimous upon this point. M. See (Joe. cit.) asserts, after 
much examination of this subject, that one-half the cases of chorea are 
dependent upon the rheumatic poison. Thus of 109 cases of rheumatism 
admitted into the Hopital des Enfants, he found that 61 were complicated 
with chorea. Trousseau 4 also states that in his experience rheumatism 
was undoubtedly the most marked cause of chorea. M. Henri Roger 5 
asserts their connection even more strongly, and states that " the coin- 
cidence of chorea and rheumatism is so common a fact that it ought to 
be regarded as a pathological law, just as much as the coincidence of 
heart disease and rheumatism." 

In England, also, this connection between rheumatism and chorea, both 
of the mild and severe or fatal form, is positively stated by numerous 
authorities. Thus in 104 cases of the list collected by Dr. Hughes, 6 
" where special inquiries were made respecting rheumatic and heart 
affections, there were only 15 in which the patients were both free from 
cardiac murmur, and had not suffered from a previous attack of rheu- 
matism." Hillier (op. cit., p. 236) " believes there is a very close connec- 
tion between these diseases." West (op. cit, 4th Am. ed., p. 188) says: 
"Be the exact relation then what it may, it does seem that rheuma- 
tism, or the rheumatic diathesis, is a very powerful predisposing cause 
of chorea." Dr. H. M. Tuckwell, in a valuable article 7 on the pathology 

i Brit, and For. Med. Chir. Rev., Jan. and April, 1868, pp. 208, 465. 

2 Chorea in Pregnancy. Proc. of Obstet. Soc. of London, vol. x, 1868, p. 147. 

3 Op. cit., 2eme ed., t. ii, pp. 565-598. 

4 Clin. Med., 2erne ed., t. ii, pp. 160-198. 

6 Arch. Gen. de Med., 1866, vol. ii, p. 641 ; and 1867, vol. i, p. 54; and Gaz. Med. 
,de Paris, March 7, 1868. 

6 Guy's Hospital Rep., 2d series, vol. iv, 1846. 

7 St. Barth. Hosp. Rep., vol. v, 1869, pp. 86-105. 



RHEUMATISM AS A CAUSE. 549 

of chorea, strongly upholds their frequent connection, and cites 17. cases 
of his own, in 11 of which the previous occurrence of rheumatism was 
allowed, while it was denied only in 6. 

Dr. Chambers found that out of 33 cases of chorea in his books, in 6 
the affection either began during rheumatic fever, or followed immediately 
after it, or else rheumatic fever succeeded to the chorea. In 80 cases of 
non-fatal chorea recorded by Ogle, 1 it appears that in 8 cases rheumatic 
fever had existed. 

On the other hand, several German authors of high authority do not 
attach so much importance to the causative influence of rheumatism in 
chorea. Thus Romberg* 2 states that he has not observed their connection 
frequently ; and Yogel 3 states that, " although it must be acknowledged 
that chorea may succeed to acute rheumatism, still the frequency of the 
occurrence has been very much overestimated." 

Steiner* also states, that out of 252 cases of chorea, the disease ensued 
during the decline of acute articular rheumatism in but 4 cases ; of 3 fatal 
cases, however, reported by him, one was complicated with rheumatic 
heart disease. 

We must also allude to the argument of Yogel (op. cit., p. 399), that 
if there were any actual connection between these diseases, then more 
girls than boys ought to suffer from rheumatism ; for it is well known that 
the former are predominantly subject to chorea. " Just the reverse hap- 
pens to be the case in rheumatism, which notoriously attacks more bo3 r s 
than girls." We have already quoted extensive statistics, which prove 
the truth of the first of Vogel's statements ; but we are by no means 
convinced that the latter is correct, and that rheumatism is more frequent 
in boys than in girls. On the contrary, the statistics quoted by Tuck- 
well (loc. cit., p. 102), go to show that the reverse even may be the case. 
Thus during sixteen years there were admitted to the Children's Hospital 
in London 4?8 patients with rheumatism, 252 of whom were females, and 
226 males. 

We are not aware of the existence of any accurate statistics of the 
disease in this countiy, in regard to this point. 

The great weight of evidence, however, which has been accumulated in 
favor of such a connection, appears to us to leave no doubt that in a 
considerable proportion of cases, though by no means in all, chorea in 
some way depends upon the existence of rheumatism, or the rheumatic 
diathesis. We shall have occasion to call attention to the obscurity which 
frequently attends the manifestations of rheumatism in young children ; 
and it is, therefore, highly probable that in not a few cases of chorea, 
where, on inquiry, the parents deny the previous occurrence of rheuma- 
tism, the truly rheumatic nature of some acute febrile attack, with which 
the child may have suffered months before, has been entirety overlooked. 

1 Brit, and For. Med. Chir. Kev., April, 1868, p. 490. 

2 Dis. of Nerv. Syst. (Syd. Soc), 1853, vol. ii, p. 57. 

3 Op. cit., p. 399. 

4 Prag. Yjrschr. xcix (xxv, 3), p. 43, 1868; in Schmidt's Jahrb., Bd. 142, ]^"o. 4, 
1869, p. 26. 



550 CHOREA. 

We will postpone, until we come to discuss the nature of this affection, 
the consideration of the manner in which rheumatism disposes to chorea, 
whether by directly causing centric lesions, as of the spinal meninges ; or 
by inducing a state of anaemia, impaired nutrition, and preternatural 
mobilit}' of the nervous s}'stem ; or whether the choreic movements are 
in some way connected with cardiac disease, which so frequently attends 
rheumatism in the } T oung. 

Exciting Causes. — Of many exciting causes that have been mentioned 
by different writers, the one most frequent and most clearly proven, is the 
influence of terror. It was assigned as a cause in 31 out of 56 cases col- 
lected by Duffosse and Bird, in 34 out of 100 cases collected bj T Hughes, 
in 25 out of 128 by See, in 9 out of 31 by Peacock, and in 9 out of 38 by 
Hillier. Besides this are cited imitation, blows and falls upon the head, 
fits of violent anger, contrarieties, masturbation, the difficult establish- 
ment of the menstrual function in girls, or suppression of that function, 
the sudden drying up of ulcers or eruptions, and, in females after puberty, 
pregnancy, which indeed is a well-ascertained and most important cause. 

Chorea has also been observed in the course of, or as a sequel to, vari- 
ous acute diseases, as pneumonia, the eruptive, typhoid, and intermittent 
fevers, and affections of the gastro-intestinal tube. 

Anatomical Lesions. — It would appear that as } T et we are unacquainted 
with any truly characteristic lesion in chorea. In many of the recorded 
autopsies, it is stated that no lesion either of the cerebro-spinal axis, 
or an}' other viscus was present. As, however, most of these autopsies 
were made before the improved methods of microscopic examination of 
the nervous s} T stem were introduced, the}' cannot be regarded as conclu- 
sive upon this point. In many cases also, the examination of other viscera 
has been too superficial to have led to the detection of minute but posi- 
tive and important lesions. Upon the whole, therefore, it may be fairly 
said, that it is chiefly the examinations which have been made during the 
past few years which are of real value, and that there is still need of nu- 
merous accurate autopsies, before we can consider ourselves justified in 
speaking of the true lesions in chorea. 

It is evident that the determination of this question presents great diffi- 
culties, apart from the fact that fatal cases of chorea are comparatively 
rare, and that it requires an amount of skill and patient labor, rarely at 
command, to make the examination with the requisite minuteness. One 
of these difficulties consists in the fact that, although chorea may exist 
as a special, individual affection, there are numerous other cases of ner- 
vous disease, which are of very varied nature, but which are attended 
with irregular muscular movements truly choreic in character. 

We think it highly probable, therefore, that all cases of so-called chorea 
will never be found to be invariably associated with any one anatomical 
lesion. 

Thus, passing to the actual results of post-mortem examination, we 
find a number of lesions recorded which evidently refer to cases of or- 
ganic disease of the nervous centres, which were merely attended with 
choreoid symptoms. 






ANATOMICAL LESIONS. 551 

Among these are enlargement of the odontoid process, effusions into 
the arachnoid, tumors in the substance of the brain, abscess in the cere- 
bellum, bony plates upon the spinal meninges, and many other entirely 
disconnected lesions. 

On the other hand there are cases on record, in which careful examina- 
tion has failed entirely to detect any material lesion, either of the nervous 
centres or of the other viscera, and in which the choreic movements were 
probably of a reflex character. 

Of late years, however, since this question has been subjected to more 
frequent and critical examination, there are certain lesions which have 
been found so frequently after death in fatal cases of true chorea, that 
thej* must be regarded as possessing some definite connection with the 
disease. These lesions consist in certain morbid conditions of the heart? 
and of the nervous centres. 

In regard to the lesions of the heart, M. See (loc. czY., p. 390) states, 
after a careful examination of eight3 T -four autopsies, that " in most of the 
cases, and especially in those most strongly attested, chorea is the result 
of the rheumatic diathesis, and that it reveals itself by plastic inflamma- 
tions of the cardiac membranes, of the pleura, and of the peritoneum, 
with or without articular rheumatism." 

Bright, Copland, Todd, 1 Kirkes, 2 Xairne, 3 Begbie, 4 were also among the 
first to call attention to the frequency of rheumatic endocarditis in con- 
nection with chorea. In an interesting article on " Maniacal Chorea," 5 
Tuckwell gives an analysis of the lesions in 34 fatal cases of chorea col- 
lected b} T himself. In 25 of these the endocardium was found diseased, 
the presence of warty vegetations on the valves being especially alluded 
to in 20. Of the remaining 9, no mention is made of the heart in 5, and 
it is reported as healthy only in 4. The pericardium was found diseased 
only in eight of the 34 cases. 

In Ogle's fatal cases {loc. c#.,pp. 208 and 507), there were in 11 out of 
17 instances more or less fibrinous deposit or granulations upon the 
valves or some part of the endocardium. In 2 cases only was the peri- 
cardium diseased. In the 14 fatal cases collected by Hughes (loc. cit.), 
vegetations were found on the valves of the heart in not less than 11. 

The results of careful auscultation, during life, come to support those 
of post-mortem examination. 

Hillier states (op.- cit., p. 236) that, " of 37 cases in my note-books 
there was probably organic disease of the heart in 25, and in 4 others 
there was evidence of functional derangement, whilst in 8 onty was there 
no sign of cardiac disturbance." 

Jules Simon writes from a large experience, and says: "I have been 
almost always able to detect well-marked evidence of cardiac affection 
in chorea, in the shape of organic murmurs, hypertrophy of the heart, 

1 Lumleian Lectures, 1849. 2 Medical Gazette, 1850. 

3 London Jour, of Med., 1851. * Edin. Med. Jour , 1852. 



Brit, and For. Med. Chir. Eev., Oct., 1867. 



552 CHOREA. 

&c. m It will be remembered that among 13 cases of rheumatic heart 
disease, reported at the end of our article on cardiac diseases, repeated 
attacks of chorea appeared in 2. 

It is sufficiently evident, therefore, that in a very large proportion of 
cases of chorea, some morbid condition of the endocardium is present. 
The particular lesion which has been usually found, consists of fine bead- 
like vegetations, which either fringe the border of the mitral valve, or are 
seated upon the auricular surface of its leaflets. 

These vegetations are in most cases readily detached from the valve, 
b}^ lightly brushing them with the tip of the finger, or with a camel'L- 
hair brush ; and it has been supposed by some observers, as Ogle and 
Barnes, that they consisted merely of the fibrin of the blood, deposited 
in the agony of dissolution. We believe, however, both from the pre- 
vious occurrence of valvular murmurs in cases where such vegetations 
have been found, as well as from a careful study of the anatomical 
descriptions of their appearances, and the occasional presence of the 
positive results of embolism, that these vegetations are produced by a 
process of endocarditis. 

We will, however, discuss the question of their connection with chorea, 
when we come to speak of the nature of that disease. 

In regard to the condition of the nervous system in fatal cases of chorea, 
there is at times no lesion appreciable, even on microscopic examina- 
tion, while on the other hand there is not unfrequently marked disease, 
either of the nervous tissue or of the meninges. 

Thus, in the 14 fatal cases collected by Hughes, the brain was healthy 
in 4. onry congested in 3 cases ; there was softening of the brain, with or 
without opacity of the membranes and serous effusion in 6, and in the 
seventh with opacit3 T and congestion of the dura mater. 

In 11 of the 35 fatal cases, collected hy Tuckwell, the brain was found 
softened, and in 9 only is it reported as healthy. In the 16 fatal cases 
reported by Ogle, the brain was healthy in 6, much congested in 8, soft- 
ened in but 1, and anaemic in 1 also. 

It appears, therefore, that in a notable proportion of the cases upon 
record, positive organic disease of the brain, and especially in the form 
of softening, has been discovered. In a few instances embolism, or occlu- 
sion of the vessels hy fibrinous masses, has been observed, either in the 
carotid artery (Ogle), or in the minute arterial branches leading to patches 
of softened brain-tissue (Tuckwell). We need, however, a large series 
of careful observations to determine more positively how frequently 
lesions of the brain occur, and especially in what proportion of cases 
embolism is present. 

The spinal cord has also been found softened with or without opacity 
and thickening of its membranes, though in a much smaller number of 
cases, probably in part because it has not been so frequently examined in 
such cases as the brain. 

i ISTouv. Diet, de Med. et de Cbir. Prat. Art. Choree (quoted by Tuckwell, St. Barth. 
Hosp. Eep., loc. cit., p. 101). 



LESIONS OF THE SPINAL CORD — SYMPTOMS. 553 

Of the 16 fatal cases reported by Ogle, its tissue was congested in 5 ; 
there was slight softening in 2 ; in 1 the upper dorsal region of the cord 
was completely broken down and almost diffluent. In 2 cases the cord 
was examined by Mr. J. Lockkart Clarke, who found in one (Joe. cit., p. 
221) that "in the lower part of the dorsal region, at the ninth dorsal 
nerves, the anterior columns were swollen, and formed a convex protu- 
berance of considerable size. In a transverse section of the cord carried 
through this part, and examined under the microscope, it was very evi- 
dent that extensive morbid changes had been going on, the white sub- 
stance had been softened, . . . and in two or three places there were 
circumscribed effusions of blood, surrounded by granular exudations, 
which had probably occurred before the effusions." Similar appearances 
were discovered in the lower dorsal region in the other case (loc. cit., 
p. 507). 

In a case, already referred to, observed by Tuckwell, of rapidly fatal 
maniacal chorea in a lad of seventeen years of age, in addition to several 
patches of embolic softening of the brain, there was marked softening of 
the spinal cord in the middle dorsal region. 

In 3 fatal cases reported by Steiner (loc. cit.), there was increase in the 
connective tissue of the spinal cord ; serous effusion in the spinal canal ; 
and congestion or effusion of blood in the membranes at the exit of the 
nerves.. 

Finally, in the cases where embolism of the brain was observed by 
Tuckwell, there was also minute embolism of the kidneys. 

In a case of fatal chorea, reported by Monckton, 1 embolism of one brach- 
ial artery occurred, and, after death, large vegetations were found on the 
aortic valves. 

"We will have occasion to refer again to these various anatomical ap- 
pearances when speaking of the nature of chorea. 

Symptoms ; Course ; Duration. — The disease may be general or par- 
tial : in the first case it affects all the limbs, the face, and some of the 
muscles of the trunk ; in the second it implicates only one side, the upper 
extremities, or a single member. It happens not rarely that the choreic 
movements are limited to one side of the body : thus in 80 cases of non- 
fatal chorea, reported by Ogle {loc. cit., p. 488), the right side alone was 
affected in 24, whilst the left alone was affected in 20 ; and in 25 both 
sides were affected, though in some instances one or the other side was 
more involved than the opposite one. Of ? cases that we have seen, in 
which this point was noted, it was general in 4, and confined entirely to 
the right side in 1, and to the left in 2. We shall describe first the pro- 
dromes of the disease, then the invasion, and afterwards the s}*mptoms 
as they exist in fully developed cases. 

Prodromic Symptoms. — It is doubtful whether there are, as a general 
rule, any well-marked prodromic symptoms. The only ones that have 
been mentioned with any authority are irritability and peevishness of the 
temper, an unusual degree of impressibility, languor, debility, disturbance 

1 British Med. Jour., 1866, No. 305. 



554 CHOREA. 

of the organic functions, exhibited by deranged appetite and an irregular 
state of the bowels, and, after a time, a certain quickness and irregu- 
larity of the movements, which mark the commencement of the charac- 
teristic symptoms of the malady. 

Invasion. — The onset of the disease is, as already stated, either sudden 
or gradual, so that there may be several days or more before it reaches 
any considerable degree of severity, or it ma} T , particularly when the case 
has been of a sudden and energetic nature, reach its height in a few hours. 
In most cases, however, it begins with some unusual and singular move- 
ments in one of the upper extremities, and as a general rule in the left. 
The choreatic movements are often observed first in the fingers, and at 
the same time or soon after, in the face. Sooner or later the}- increase 
in severity, and extend to the other arm, to the legs, and to the tongue, 
and the disease is fully developed. 

Symptoms of Confirmed General Chorea. — When the disease has be- 
come fully confirmed the movements are exceedingly diversified and 
irregular. The limbs are agitated by involuntary contractions of the 
muscles into eveiy attitude possible for them to assume. The fingers are 
opened and shut, brought together or separated, without any regularity. 
The hands are flexed and extended upon the forearms, or pronated and 
supinated, whilst the forearms are flexed or extended upon the arms, and 
the arms moved at the shoulders into every imaginable position. Such 
are the irregularity and rapidity of the motions that it is often with great 
difficulty that the patient can seize anything with the hands, and when 
once the object is attained, he frequently cannot do with it what he wishes. 
This imperfect control over the hands and arms sometimes prevents the 
patient from carrying food and drink to the mouth, excepting with the 
utmost difficult}', and may make it necessary to feed the child. 

The inferior extremities are affected in the same way as the arms. 
Walking is alwaj's more or less difficult, and in some severe cases im- 
practicable. The patient totters from side to side, or walks rapidly a 
short distance, and then suddenly stops. Sometimes the progress is ac- 
complished in a zigzag direction, and at others hy fits and starts as it 
were, whilst in others again, the walk is rapid and sudden, almost a run. 
The child often falls while walking or running, either from meeting a 
slight obstacle, or in consequence of the irregular and imperfect muscular 
action. In some instances standing is impossible, the knees bending 
suddenly under the weight of the body. It was no doubt the peculiar 
irregular and dancing movements of the inferior extremities during the 
attempts to walk and stand, that gave to the disease its original name of 
St. Yitus's dance. 

The convulsive movements of the face and head are not less singular 
than those of the limbs. The face is distorted into all kinds of expres- 
sions, st> that it assumes by turns that of the most opposite emotions, — 
sadness, terror, jo} T , or grief. The mouth is opened and shut, or its cor- 
ners drawn apart, with the greatest irregularity ; the tongue is occasion- 
ally protruded between the teeth, and sometimes moved rapidly in the 
mouth, so as to cause a clacking sound ; the lower jaw is depressed and 



SYMPTOMS. 555 

elevated, or moved in a lateral direction, and with snch violence perhaps 
as to injure the tongue or teeth. In consequence of the irregular mo- 
tions of the tongue and mouth, articulation becomes difficult and the 
child either stutters, or speaks slowly and badly, or can pronounce only 
monosyllables. In a case that occurred to one of ourselves, the move- 
ments of the mouth and tongue were so violent and uncontrollable that 
the patient, a boy nine years old, lost for three weeks all power of speech. 
He was at the same time unable to open or shut the mouth at will, or to 
swallow at the proper moment, so that in the act of feeding him, which 
became necessary from his entire want of control over the arms, the food 
was constantly spilled and spluttered about as though by an idiot. The 
act of mastication also was quite impossible, so that he could take nothing 
but fluids for a number of weeks. In another case also that occurred to one 
of ourselves, in a girl between eight and nine } T ears of age, and which more- 
over was a relapse, the patient exhibited the same inability to feed her- 
self, and the same difficulty in regard to mastication, so that she had to 
be nourished for several weeks on soft food. The speech was likewise 
greatly affected, it being very difficult to understand her muffled, thick, 
and indistinct utterance. 

Whilst the face and limbs are contorted as above described, the head 
is moved rapidly from side to side, or backwards and forwards, or under- 
goes constant rotation, and, in some instances, as in two that came under 
our own notice, all power over the muscles of the back of the neck is lost, 
and the head falls from side to side, or forwards, as in an infant. In 
severe cases the choreatic movements affect the trunk also, so that the 
patient cannot lie upon a bed, but rolls and twists about the floor with 
such violence as to bruise and excoriate the skin. Deglutition is some- 
times slightly embarrassed, and the child is obliged to swallow with great 
rapidity ; in some few cases a peculiar loud cry, like that which occurs in 
lrvsteria, dependent apparently upon spasm of the larynx, has also been 
observed. The muscles of the external and internal respiratory appa- 
ratus are rarely affected, though Romberg narrates three remarkable 
instances, in which dyspnoea, loud whistling respiration, spasmodic con- 
tractions of the glottis, or hiccough, were present. Occasionally irregu- 
lar action and palpitation of the heart are observed, and have been attrib- 
uted to chorea of its muscular structure. 

In some cases, also, the sphincters of the bladder or rectum are par- 
tially paralyzed. Retention of urine has been noticed in a few cases ; 
and, on the other hand, the late Prof. William Pepper mentions having 
known incontinence of urine to alternate with chorea of the external 
muscles. 

The disease is unaccompanied by pain unless it be attended with some 
complication, and what is very singular and remarkable, the constant and 
often very violent muscular contractions do not seem to occasion fatigue. 

There is, however, frequently evidence of a want of muscular power, 
which may merely amount to an unusual susceptibilhVy to fatigue on vol- 
untary exertion ; or complete paralysis may be present, especially in the 
form of hemiplegia, in cases of unilateral chorea. 



556 CHOREA. 

The general S3 T mptorns require some attention. The choreatic move- 
ments are almost alwaj's increased by emotion, as terror, anger, contra- 
rieties, and by the consciousness of being observed. Sleep generally 
suspends them entirely. In very bad cases they are said to produce 
insomnia, or to wake the child frequently in the night. The intelligence 
is rarely affected, except in very severe and long-continued attacks ; 
though some authors appear to have met with frequent instances of im- 
pairment or perversion of the intellectual faculties. The temper is often 
irritable and capricious. General and special sensibility commonly re- 
main natural ; though in some cases, impairment of general sensibility of 
the parts most convulsed, even amounting to anesthesia, is noticed. In 
simple, uncomplicated attacks, the pulse, as a rule, remains natural ; the 
appetite is preserved ; there is no unusual thirst, and the bowels continue 
regular. 

The urine has at times been observed to be of unusually high specific 
gravity, and to contain an excess of urates and oxalates. These condi- 
tions do not, however, appear to be at all constant or characteristic. 

In a considerable proportion of cases of chorea (see statistics on page 
551), a bruit is heard on ausculting the heart, usually of low pitch, and 
not very great intensity. In some cases this is undoubtedly due to the 
vegetations so frequently found on the valves of the heart in this disease, 
but in others it appears to be rather due to the anaemic state of the blood ; 
and in those cases where palpitation exists, it may be due to the irregu- 
lar contractions of the walls of the heart. It has also been noticed that 
these murmurs in chorea are often transitory, and even intermitting. 

It is said that idiocy is apt to occur in cases which last for a number 
of years. 

The course of the disease is acute or chronic. In a large majority of 
cases it is acute, the symptoms becoming more and more violent until 
they reach their height, when they remain stationary for a time, and then 
subside and disappear under the influence of treatment, or in the natural 
course of the malady. It has been frequently noticed that when an acute 
febrile or inflammatory disease is developed during the course of chorea, 
the spasmodic movements are very apt to diminish or entirely cease for 
the time. In fatal cases the symptoms are constantly aggravated ; the 
movements become so violent as to make it necessary to secure the child 
in bed, or in a strait-jacket ; the patients, deprived of sleep, become feeble 
and emaciated ; the respiration becomes difficult ; intelligence is abol- 
ished ; the pupils are contracted ; and the child dies. 

The duration is irregular, varying in acute cases between one and three 
months. The average duration is probably about six or nine weeks. In 
very slight attacks it may be much less. The duration of chronic cases 
is from months to years. In fatal cases the duration is sometimes very 
short. In one it was only nine, and in another twenty-seven claj^s. The 
local forms of the disease are often peculiarly intractable, and last many 
years. 

Relapses. — Relapses are quite common, and are said by Trousseau to 
be shorter than the original attack. They occurred in two of the nine 



NATURE OF CHOREA. 557 

cases observed by ourselves. In one of these the relapse was much worse 
than the first attack. It was one of the most violent and prolonged that 
we have seen. MM. Rilliet and Barthez state they occurred in six out 
of nineteen cases seen by them. The relapses in these cases occurred 
once, twice, and three times. M. See (Joe. cit., p. 408), says that it is not 
uncommon, after some weeks of respite, or several months of apparent 
recovery, to see the disease reappear with renewed intensity, and be thus 
repeated twice, thrice, and even seven times in succession. Out of four 
patients, at least one, he states, remains thus under the influence of the 
disease. Of 158 cases he counted 37 relapses, of which 11 were arrested 
after the second attack ; 13 suffered a third, and 6 a fourth attack ; and 
lastly, one had seven distinct seizures, each one of which was separated 
from the following, by a well-marked interval. In 46 of Ogle's cases in 
which this point was noted, previous attacks had occurred in 25 ; in 5 of 
which there had been 2 previous attacks, and in 1 no less than 7. 

Nature of Chorea. — In considering the essential nature of chorea, it 
is evident that there are two points of importance to be determined, 
namely, the precise portion of the nervous system involved, and the 
nature of the morbid change in this part. 

Before alluding to the views which have been entertained in regard to 
the first of these questions, we would refer to the very great irregularity 
which exists in different cases in the extent and distribution of the cho- 
reic movements. Thus it frequently happens that the disease is strictly 
confined to one or the other side of the body, or it may be entirely sym- 
metrical. In other cases the muscles of the head and neck may almost or 
quite escape, while both legs and one or both arms are affected. Or, on 
the other hand, the choreic movements may first appear and remain most 
severe in the muscles of the face, mouth, and tongue. It seems probable 
to us, therefore, that there is no one special portion of the motor centres 
which is exclusively the seat of lesion in all cases of chorea. In the great 
majority of cases, however, the symptoms are so far uniform that the 
muscles of the face and tongue, as well as those of the extremities, are 
affected, and the only peculiarity is that the irregular movements may 
be confined to one or the other side, a circumstance susceptible of ready 
explanation. 

Marshall Hall considered chorea as an affection of the true spinal sys- 
tem, and possibly in some cases where the choreic movements are limited 
to the extremities and symmetrical, this supposition may be correct. 

In the vast majority of cases, however, it is undoubtedly necessary to 
locate the seat of disturbance in chorea at a higher point in the cerebro- 
spinal axis, one above the decussation of the anterior pyramids, and 
probably in or near the corpora striata. Among the arguments which 
lead to this view, many of which have been advanced by J. Hughlings 
Jackson * and Broadbent, 2 who strongly uphold it, may be stated the fol- 
lowing: That the muscles of the face are very frequently affected by the 

1 Eeynolds's Syst. of Med., Art. Chorea, vol. ii, p. 127, foot-note; and Med. Times 
and Gaz., March 6th, 1869. 

2 British Med. Jour., 1869. 



558 CHOREA. 

choreic movements ; that in the great majority of cases the movements 
cease during sleep ; that the affection is frequently limited to one side of 
the face and body, and that the spasmodic movements not rarely termi- 
nate in complete hemiplegia. In a foot-note (loc. cit., p. 93) Tuckwell says : 
" It is just to Dr. Todd's memory to add, that he long ago (Lancet, 1843, 
vol. ii, p. 463) showed that the choreic phenomena caunot be explained 
by the hypothesis which refers them to irritation of the spinal cord. He 
says : ' The hemiplegic tendency is utterly inexplicable according to that 
view. The affection of one-half the bod}' would alone refer to some point 
above the decussation of the pyramids as the seat of irritation.' " The 
supposition of Carpenter and others that the cerebellum is the seat of the 
disturbance in chorea, was based upon the view that that organ possessed 
the chief power of co-ordinating muscular movements. Recent researches 
into the functions of the cerebellum, as well as the arguments which have 
been adduced above, render this supposition untenable. 

The further question now remains as to the condition into which the 
affected part of the motor centres is brought, in order to produce the 
phenomena of chorea. And it is especially in regard to this point that 
the investigations of Jackson and Broadbent, above referred to, are of so 
much value. These pathologists, and particularly the latter, have called 
attention to the fact that the choreic phenomena are s} T inptomatic merely 
of the seat of the disease, and that the only essential condition of their 
production is an impairment of vigor and instabihMy of the sensori-motor 
ganglia, a condition which inay probably be induced in different ways. 

TVe are now prepared to consider the manner in which the various 
causes of chorea may be supposed to act. 

We have already seen that in a certain number of cases (according to 
See, sixteen in eighty-four) chorea is independent of any appreciable 
lesion of the nervous sj'stem. In some of these cases it is possible that 
the impaired nutrition of the motor centre may result from an altered 
and anaemic state of the blood; and, indeed, it appears to us quite as 
reasonable to explain a certain class of cases of chorea in this manner, as 
to apply the same explanation to analogous cases of paralysis. 

It is probable, also, that in another group of cases, chorea may be 
reflex in character, and depend upon a different degree of that peculiar 
action upon the motor centres which produces reflex paralysis, whether 
by exhausting their excitability or by causing a reflex spasm of their ves- 
sels. This view is maintained b}' Broadbent (Joe. cit.) as well as by Rad- 
cliffe, 1 who states that irregular choreic movements may be produced not 
only by injury of certain parts of the nervous system, but b} T injury of 
certain nerves at a distance from the nervous centres, the portions of the 
cerebro-spinal axis which are concerned in the development of such move- 
ments, being affected by reflex action. 

It is probable that if this mode of production be admitted, it will serve 
to explain a large number of cases of chorea, both where the source of 
irritation is at a distance (as in cases of pregnane}', or where there are 

1 Reynolds's Syst. of Med., Art. Chorea, vol. ii, p. 126. 



NATURE OF CHOREA. 559 

worms in the intestinal canal) and where it is seated in immediate con- 
nection with the nervous centres. As instances of the latter kind, may 
be suggested such conditions as thickening of the meninges of the brain 
or spinal cord, and the presence of bony spiculse developed in the me- 
ninges. 

Finally, we must admit as a cause of chorea, primary alterations of the 
tissue of the sensori-motor ganglia and adjacent parts; the degree of dis- 
ease not being so great as to abolish entirely their function and produce 
paralysis, but only sufficient (as for instance would be secured by an early 
stage of softening) to weaken it and render it unstable. 

It will be seen from the foregoing remarks that we deem it impossible, 
at least in the present state of our knowledge upon the subject, to con- 
sider the cause and mode of production essentially the same in all cases 
of chorea, and that we are disposed to admit the existence of cases due to 
mere anaemia and impaired nutrition, or to an altered state of the blood; 
of cases due to reflex irritation (in both of which classes of cases, some mi- 
nute and as }~et inappreciable lesion may exist) ; as well as of cases which 
are due to primary material alterations of the sensori-motor ganglia. 

"We have alreacty, in considering the causes and anatomical appear- 
ances of chorea, had occasion to dwell upon the close connection which 
exists between it and rheumatism, and before leaving the present subject 
it is desirable to refer to the various explanations which have been offered 
of this circumstance. Among these, the most important and interesting 
is that of Kirkes, 1 who, noticing the frequent presence of vegetations 
upon the valves of the heart in fatal cases of chorea, was led to suggest 
that very small fragments of fibrin might be detached from the valves, 
and entering the circulation cause temporary obstruction of the minute 
capillaries of the nervous centres, producing irritation and impaired nu- 
trition. This theory, which attributes the production of chorea to em- 
bolism, has been accepted by J. Hughlings Jackson (loc. cit.), by Savory, 2 
by Tuckwell (loc. cit.), and, in part at least, by Broadbent (loc. cit.). 

It is supported strongly by the facts that continued observation of 
cases of chorea has shown even more clearly the very frequent existence 
of cardiac murmurs during life, and of vegetations upon the valves after 
death ; that complete paralysis, usually in the form of hemiplegia, fre- 
quently -follows the choreic movements; that in many fatal cases there is 
found just such cerebral softening as follows embolism; and, finally, that 
in a few cases, alread}^ referred to, the existence of embolism has been 
actually demonstrated. 

There have, however, been numerous objections advanced against this 
theory, the most powerful of which are urged by Barnes (loc. cit.) and 
Ogle (loc. cit.). Thus it has been objected that, on the supposition of 
numerous minute fragments of fibrin circulating in the blood and becom- 
ing impacted in the minute capillaries, it would be difficult to explain the 
fact that chorea is so frequently unilateral, or even localized in a single 
group of muscles. It must be remembered, however, in answer to this, 

1 Med. Times and Gaz., 1863, vol. i, pp. 636 and 662. 

2 St. Barth. Hosp. Rep., vol. i, 1865, p. 107. 



560 CHOREA. 

not only that in some cases of fatal chorea embolism of single large arte- 
rial branches has been found, but that the number of minute fragments 
of fibrin detached from the heart's valves may be very small, and that it 
is quite supposable that they should nearly all pass into the innominate, 
or less frequently the left carotid artery, and thus be chiefly distributed 
to one side of the brain. It may be mentioned also in this connection, 
that it is especially in these cases of unilateral chorea that the affection 
is succeeded by paralysis, such as might readily follow in case of em- 
bolism. 

Again, it has been objected that if chorea be invariably dependent 
upon embolism, the results of this accident must be of a very transient 
and trifling character, since in so great a majority of cases the disease 
terminates in complete and permanent recovery. The weight of this 
objection must be admitted, and yet Tuckwell fairly remarks in answer to 
it, that the "mere fact of recovery is not enough to condemn the notion 
of embolism. On the other hand, the very frequent presence of a cardiac 
murmur, even in the milder attacks of chorea which recover, would rather 
dispose me to look for the same exciting cause in the mild as in the 
severe cases, viz., embolism." 

Another objection advanced by Ogle (loc. cit., p. 232) is, that in other 
cases of capillary embolism the symptoms produced are not those of cho- 
rea, but rather of pyaemia or of gangrene. It is quite evident, however, 
that these symptoms alluded to (which are met with for instance in ulcer- 
ative endocarditis) are due, as remarked b}^ Savory and Tuckwell, not 
to the mere capillary embolism, but to the concomitant septic condition 
of the blood. 

This extremely interesting question cannot be considered as definitely 
settled ; there is still needed a series of careful examinations in regard to 
the A T arious points under discussion. It appears to us, however, conclu- 
sively shown that, in a certain number of cases, the peculiar irritation 
and impaired nutrition of the sensori-motor ganglia, which leads to the 
development of the choreic phenomena, are due to embolism of the ves- 
sels supplying these parts. We have, however, already expressed our 
opinion that, at present at least, there must be admitted two other classes 
of cases of chorea, due primarily to alterations in the blood and to 
reflex irritation respectively. It is quite possible, therefore, that in some 
instances rheumatism induces chorea indirectly, either by causing anaemia 
and impaired nervous vigor, or by causing inflammatory lesions, as of 
the spinal meninges, or sheaths of spinal nerves, which may serve as the 
foci of reflex irritation. 

Diagnosis. — The diagnosis of chorea cannot be attended with any diffi- 
culty, and we shall therefore make no remarks upon it. 

Prognosis. — Idiopathic simple chorea in young children is rarely a 
fatal disease. ^Nevertheless, even under these circumstances, it sometimes 
terminates fatally, and usually from exhaustion. Thus MM. Rufz, Legen- 
dre, and Rilliet and Barthez have each met with an instance. M. See 
(loc. cit., p. 406) states that of 158 cases, 4 passed into the chronic con- 
dition, and 9 proved fatal. Dr. Copland states that he has met with 3 or 



PROGNOSIS. 



561 



4 fatal cases, that Dr. Prichard lias recorded 4, and that Dr. Brown refers 
to 3 in his practice ; but he does not inform us whether they were idio- 
pathic, complicated, or symptomatic. We have alread}^ referred to the 
list of 14 fatal cases, of which the autopsies were reported by Dr. Hughes 
(loc. cit.) ; and to the 34 additional fatal cases collected by Tuckwell (loc. 
cit.). Dr. J. W. Ogle has lately (Brit, and For. Med. Chir. Bev., January 
and April, 1868) published the details of 19 more fatal cases ; and from the 
same source we quote the following table as exhibiting the mortality from 



this disease in Great Br 



Dea 



1839, 
1840, 
]841, 
1S42, 
1847, 
1848, 
1849, 
1850, 
1851, 
1852, 
1853, 
1854, 



ain during 23 years. 



s from Chorea. 








. 54 


1855, . 




. 25 


1856, 






. 28 


1857, 






. 19 


3858, 






. 39 


1859, 






. 38 


1860, 






. 34 


1861, 






. 60 


1862, 






. 77 


1863, 






. 73 


1864, 






. . 67 


1865, 






. 48 


Tota 


l dur 


mg23 



Deaths from Chorea. 

. 69 

. 59 

. 44 

. 53 

. 55 

. 66 

. 71 

. 52 

. 63 



16 

88 



years, 1255. 



It is quite possible, however, that many cases of organic disease of the 
nervous system merely attended with irregular choreoid muscular move- 
ments have been included in these reports. On the other hand, out of 
84,332 deaths at all ages occurring in this city during seven consecutive 
years, but 3 are attributed to chorea. It must not, however, we think, 
be posit ivelj- inferred from this .that severe and fatal chorea has been 
really so rare among us ; since, during the same time, there are reported 
in addition to the deaths from convulsions, 79 deaths from cramps, a 
vague and most improper term, which, in all probability, includes a cer- 
tain proportion of cases of chorea. 

In regard to any special rules in prognosis to be deduced from a study 
of the fatal cases, it may be observed that their average age is consider- 
ably greater than that of ordinary mild chorea. Thus in It out of Ogle's 
19 fatal cases, but two were under the age of ten ; the average being 
15|ths years. 

So too in 32 of Tuckwell's 34 fatal cases, 21 were at or above the a° - e 
of fourteen, and 6 of this 21 were at or above the age of twenty. 

The duration of the case scarcely seems to have a direct bearing upon 
its fatality. It is true that in cases which have passed into the chronic 
form and persisted for several months, the prospect of being able to effect 
an entire cure diminishes, but still such patients may live very many 
years and ultimately die only from some intercurrent disease. And, on 
the other hand, death has been known to occur as early as the end of the 
first week. Of course the existence of smy serious complication, and 
perhaps especially of marked cardiac disease from previous rheumatic 
attacks, renders the prognosis unfavorable. 

36 



562 CHOREA. 

In conclusion, whenever, in a case of chorea, the convulsive movements 
become incessant, and the respiration embarrassed, and still more when 
snbsultus tendinum takes the place of the choreic movements, a fatal 
termination is greatly to be apprehended. 

Treatment. — Many different plans of treatment, and a great variety 
of drugs have been proposed for the cure of the disease under considera- 
tion. These facts alone may serve to teach us that the effects of treat- 
ment are not clearly appreciated, aud also, when taken in connection with 
the circumstance that fatal cases are rare, that the disease tends naturally 
to recovery in a good proportion of the cases. This feature of the natural 
history of the disease is shown also hy the evidence given by Dr. Bard- 
sley, who mentions, that in the Manchester Infirmaiy, notwithstand- 
ing the variety of treatment adopted by successive practitioners, an in- 
curable case has not presented itself in the course of thirty-three years. 
(Tiveedie's Lib. Pract. 3fed., Am. ed., vol. ii, p. 46.) 

The only rules to be laid down for its treatment are those which apply 
to all the convulsive affections depending on functional disorder of the 
nervous system, and on disordered states of the general health, connected 
with a faulty condition of the functions of digestion and assimilation. 
These are attention to the general health, and especially a careful regula- 
tion of the diet and other hygienic conditions of the patient, and the use 
of tonics and iron, the removal of any local derangement or disease that 
may exert an unhealthy influence upon the nervous system, and the em- 
ployment of such remedies as have been found to exert a controlling 
effect upon spasmodic and convulsive affections generally, and upon this 
disease in particular. 

We shall consider, under different heads, the various means that have 
been recommended, endeavoring in the course of our remarks to dis- 
tinguish the cases to which each remedy is best adapted. 

Purgatives. — This class of remedies has been extensively emplo} T ed and 
often exclusively relied upon by some veiy high authorities, especially 
the English. When relied upon exclusively in the treatment, an active 
cathartic is given eveiy day, or every second or third day ; and there can 
be no doubt that many cases have recovered under this plan. In our own 
practice we must say that the treatment by cathartics alone has never 
succeeded well, and we have only used them of late to such an extent as 
was necessary to secure a soluble and healthful condition of the bowels. 
When, therefore, the stools are natural and healthful in all respects, we 
do not think it proper to employ powerful purgatives in the treatment of 
the disease. We resort to them only when there is constipation, or when 
the discharges present some unnatural appearances as to color, odor, &c. 
Under the latter circumstances we may resort to any of the somewhat 
active cathartics, as cream of tartar and jalap, sulphate of magnesia, rhu- 
barb, aloes, &c. When the discharges from the bowels are clay-colored, 
or dark and offensive, when the mouth is pasty, the tongue loaded with a 
thick yellowish fur, and the breath heav} 7 , it is proper to employ a mer- 
curial. Dr. Copland advises that we should commence with the exhibi- 
tion of a full dose of calomel, either alone or with other purgatives, or 



TREATMENT. 563 

followed by tliem in five or six hours. He adds that the doses of calomel 
ought not to be frequently repeated in the disease, and thinks that it is 
not serviceable "to continue purgatives long, without either exhibiting 
them with a bitter tonic or antispasmodic remedy, or with both, or alter- 
natiug them with those remedies." 

Antispasmodics are amongst the most important remedies we have to 
oppose to the disease. The weight of evidence seems to show, indeed, 
that they, in conjunction with a moderate use of purgatives, of tonics, 
especially ferruginous tonics, of certain and particular remedies, and care- 
ful regulation of the hygienic conditions of the patient, ought to consti- 
tute the treatment in the great majority of cases. Of the various reme- 
dies of this class that haA r e been employed, those which have exerted the 
most beneficial influence are valerian, assafcetida, oxide of zinc, camphor, 
and the root of the cimicifnga or black snake-root. 

Particular remedies. — Of the remedies belonging to this class, the one 
most employed in this city at present is, we think, the cimicifnga. This 
was first introduced into use by Dr. Jesse Young, and is now extensively 
employed and much relied upon. Dr. Wood (Pract. of Med., vol. ii, p. 
755), says : "I have in repeated instances found it of itself adequate to 
the cure of the disease." We have emploj'ed it ourselves only in four 
primary cases, and in two cases of relapse. In three of these, the children 
recovered entirely under its use ; in one it failed to do any good, and re- 
covery took place under the use of iron, the sea-bath, and in the course 
of time. In the two relapsed cases, the patients recovered finally under 
the use of the cimicifnga, iron, cod-liver oil, and good diet. One of the 
cases that recovered under its use was much the worst we have ever met 
with. It was that of a boy of nine years, in whom the disease went so 
far as to destroy all power of locomotion. The child was unable even to 
stand. At the same time the movements of the lips, cheeks, and tongue, 
were so violent and irregular, and so little under the control of the will, 
that the power of speech was lost entirely for a period of four or five 
weeks. The choreatic spasm appeared to affect even the muscles of de- 
glutition, so that the act of swallowing was often difficult and uncertain. 
Mastication also was impossible, and the child was unable to carry any- 
thing to his mouth, rendering it necessary to feed him, as one would a 
babj^, with soft solids and fluids. During some two months, the muscles 
at the back of the neck were so weakened that the head could not be lifted 
from the pillow or held direct, but fell from side to side or forwards like 
that of an infant. The condition of the child was altogether one of the 
most complete and distressing helplessness. During the first month of 
the case, it was treated with active cathartics, chiefly very large doses of 
cream of tartar and jalap, and with iron, but as the symptoms became 
worse and worse, the cathartics were abandoned except so far as to main- 
tain by the occasional use of rhubarb and senna, a soluble state of the 
bowels, which were very much disposed to constipation. The patient was 
now put upon the use of decoction of cimicifnga, of which he began with 
four ounces, soon increased to half a pint per day, made in the proportion 
of half an ounce to the pint. The iron was continued. Under this treat- 



564 CHOREA. 

merit he very soon began to amend, and in two weeks showed a very de- 
cided improvement. Cod-liver oil was now added to the iron and cimi- 
cifuga, and in six weeks he was in great measure restored to health, and 
in the end recovered completely. In another case almost as bad as this, 
the patient finally recovered under the same treatment. 

The cimicifuga is given in powder, tincture, decoction, or fluid extract, 
and should be continued for several weeks in gradually increasing doses, 
until some visible effect is produced, as nausea, headache, vertigo, or dis- 
ordered vision. The usual doses are from half a drachm to a drachm of the 
powder, from one to two ounces of the officinal decoction, and one or two 
drachms of a saturated tincture, given three times a day. For our own 
part we prefer the decoction, of which we give to children of eight or 
nine years old, from four ounces to half a pint a da}^, made in the pro- 
portion of half an ounce of the root to a pint of boiling water. Prepared 
in this way, it is not a disagreeable drink, and is usually taken without 
much objection. 

Some French authors recommend chiefly valerian, oxide of zinc, and 
assafoetida. Of these the one which has the highest reputation is valerian, 
and from the evidence adduced in its favor there can be no doubt that it 
exerts a very beneficial effect upon the disease. It may be given in the 
form of powder, infusion, or fluid extract. The dose of the powder is 
from' twelve to eighteen grains in the day, to commence with, to be rap- 
idly increased to several drachms, as the stomach becomes accustomed 
to it. It may be given in honey or preserve-syrup. We should prefer 
the fluid extract, of which half a teaspoonful may be given to a child eight 
or ten years old, three times a day, and the quantity gradually increased. 
The oil of valerian is employed by some practitioners. Oxide of zinc is 
given in doses of a grain every three hours to children eight years old, 
and is much relied upon by some practitioners. Assafoetida is recom- 
mended both b} 7 English and French writers. It is best given in pill, on 
account of the nauseous taste of the mixture. Two three-grain pills may 
be given to a child of four or six years of age, three times a day. Dr. 
Bardsley gave it by injection, in combination with laudanum, every eve- 
ning, after using musk and camphor through the d&y. 

Narcotics have been recommended by some writers. Those which are 
most emploj'ed are opium, belladonna, stramonium, and cannabis Indica. 
Substances of this class are seldom, however, made the basis of treatment. 
Opium is useful in some cases in which the agitation is very great, so that 
the sleep of the child is much disturbed, but it is seldom necessary except 
as an adjuvant to other means ; and the remark applies equally to other 
remedies of the class. 

Arsenic. — There is no remedy in regard to whose curative action in 
chorea testimony is more unanimous. Romberg and Begbie speak of 
it, as curing the affection in as short a time and with even greater 
certainty than any other remedy; and Trousseau also testifies to its 
good effects, but adds that it has the disadvantage of being difficult of 
administration, owing to its irritant properties. Dr. Raclcliffe, who has 
met with the same difficulty in maintaining the use of full doses of this 



TREATMENT. 565 

remedy for any length of time, has tried with apparently marked success 
the hypodermic injection of Fowler's solution. He was first led to em- 
ploy this in cases of chronic local chorea in adnlts, where the injection of 
doses of Fowler's solution, varying from five to fourteen minims, produced 
a speedy cure. He has also emploj-ed it successfully in two cases of gen- 
eral chorea, the duration being twenty-eight and thirty-two da}'s respect- 
ively. 

The usual manner of administration is in the form of Fowler's solution, 
given in the ordinary doses, and immediately after eating, and steadily 
persisted in until some evidence of its constitutional effects are produced. 
This preparation may also be advantageously combined w r ith the wine of 
iron. 

Strychnia. — Trousseau recommends more highly than any other plan 
of treatment, the use of sulphate of strychnia in gradually increasing 
doses, until the extreme limit of tolerance is reached. He begins by giv- 
ing gr.Jgth twice or thrice daily, to children between five and ten } r ears 
old, and cautiously increases this dose until it reaches about gr.fth in 
twent3'-four hours. The results obtained by this treatment in Trousseau's 
hands certainly appear good, but the risk attending it and the care de- 
manded to prevent accidents are so great, that we should prefer some of 
the equally successful and less dangerous methods. It appears, how- 
ever, that other observers, as West, have obtained good results from its 
use in doses much smaller than those recommended by Trousseau, not 
exceeding gr.fth thrice daily, for children of eight or ten years of age. 

Conium maculatum, given in the form of the succus conii, has been 
highly recommended by Dr. John Harley ( The Old Vegetable Neurotics, 
London, 1869), in the treatment of chorea; and a certain number of 
cases have already been reported of its successful administration. Dr. 
Harley prescribes the succus in the doses of 20 or 30 drops for a child of 
six months old ; a drachm for one over two years old ; and from one to 
two drachms at ten years of age. In explaining the use of doses so large 
as these, he insists upon the fact " that hemlock given in doses which fall 
far short of producing its proper physiological action, is useless for the 
treatment of the diseases to which it is adapted." 

Stimuli. — The well-known views of Dr. Radcliffe upon the pathology of 
spasmodic affections, have led him to recommend the free use of alcoholic 
drinks, to the point of obtaining their decidedly sedative action on the 
economy, as the foundation of a rational treatment in chorea. 

Without being prepared to adopt this as a regular plan of treatment 
for ordinary cases of the disease, we should certainly be disposed to ad- 
minister alcoholic stimuli whenever the symptoms indicated the approach 
of nervous exhaustion. 

Tonics. — Whenever the disease occurs in debilitated and anaemic indi- 
viduals, remedies of this class are evidently necessaiy, and prove of great 
efficacy. The ferruginous preparations are those most clearly indicated 
under the circumstances ; and, indeed, there are many authorities, as 
Watson, Elliotson, and others, who consider the preparations of iron suffi- 
cient, of themselves, to cure almost all cases of chorea. Any of them may 



566 CHOREA. 

be selected. The best are the subcarbonate, Yallet's pills, the syrup of 
the iodide, and the pare metallic iron (ferniui per lrydrogen). Quinine is 
also recommended when the patient is feeble and weak. It may be given 
alone or in combination with iron. The citrate of iron and quinine would 
form a very good prescription under the circumstances mentioned. Cod- 
liver oil is an admirable remedy when the child is thin and weak, and 
especially when there is cause to suspect airy tubercular predisposition. 

The cold plunge and shower bath have also been resorted to by a num- 
ber of practitioners, and there is evidence to show that they have often 
proved useful. The cases in which the}' are used should be selected, 
however. They ought not to be employed unless followed by full reac- 
tion, nor unless the child is willing to take them. When the use of the 
bath terrifies or shocks the patient greatly, it cannot be proper. A warm 
or tepid bath used once a da}', or eveiy second day, would alwaj'S be 
useful in promoting the general health, when the cold bath is not borne 
well. 

Sulphurous baths have been recommended and empkyed with much 
success, by M. Baudelocque of Paris. A rapid and definite cure was ob- 
tained in 58 out of 65 cases. Thirty drachms of sulphuret of potassium 
are added to each bath, which is employed for at least one hour daily, at 
a temperature of 91°. Generally amelioration occurs after the second or 
third bath, but sometimes not until after twelve or fifteen clays, a mean 
of twenty-two days having served for the cure of fifty out of fifty-seven 
cases. Where the cure is retarded, it ordinarily depends upon the pa- 
tient's powers being lowered by other remedies or insufficient diet, upon 
irritation of the skin induced by the bath, or upon acute irritation of the 
internal serous membranes : circumstances contraindicating the baths 
while they continue. The conjunction of other remedies retards rather 
than aids the case. Deducting the cases in which the bath was improp- 
erly used under the above circumstances, there remain but nine true fail- 
ures in eighty-one cases, these being almost all recent or rheumatic 
choreas. (See on Chorea, Rojilcing-s Abstract, Xo. 16, p. 51.) 

A great variety of remedies besides those we have mentioned have been 
employed, and have more or less evidence in their favor. Amongst them 
are sulphate and iodide of zinc, nitrate of silver, subnitrate of bismuth, 
iodine, calabar bean, and a host of others which it is useless to enumer- 
ate. The sulphate of zinc has undoubtedly proved efficacious in some 
instances. About two grains may be given at first three times a day, 
and gradually increased to six or eight if the stomach bears the remedy 
well. 

Counter-irritation to the spine, in all its shapes, from pustulation with 
tartar emetic, issues, and blisters, down to frictions with coarse towels, 
has been proposed and eruphyyed in the treatment. The use of any but 
the milder remedies of this class is unnecessarily harsh and cruel, except 
when the disease is evidently dependent upon an affection of the brain or 
spinal marrow. The great majorit}' of cases will recover perfectly well 
without a resort to such violent means, and they ought therefore to be 
avoided. 



TREATMENT. 567 

Electricity lias been resorted to, and apparently with good effects in 
some instances, and it might therefore be tried when other and simpler 
means fail, or in conjunction with these means. In cases where the spas- 
modic movements are constant and persistent despite the use of internal 
remedies, the inhalation of anaesthetics has been tried, but with uncertain 
results. 

In violent cases, it is of course desirable to confine the patient to bed ; 
and it ma}' be necessary to have padded sides made for it to prevent him 
from dashing himself out of bed in his uncontrollable and violent move- 
ments. In such cases it may even become necessary to employ padded 
splints, or to envelop the body with bandages carefully applied over layers 
of wadding, so as to secure the legs together, and to confine the arms by 
the sides. 

Gymnastic Exercises. — M. See (loc. cit., p. 481) says that this method 
is one of the best that has been employed. He states that it was recom- 
mended by Darwin, and then by Mason Good, and was first employed 
by Louvet Lamarre in one case, after which it fell into oblivion until 
some of the physicians of the Children's Hospital, at Paris, and amongst 
others, MM. Bouneau, Baudelocque, Guersant, and Blache, " struck, no 
doubt, like nryself, with the good effects of gymnastics in scrofula and 
other cachectic diseases, and taught especially by the effects of mus- 
culation on the general health, conceived the idea of applying this treat- 
ment to nervous diseases, and particularly to chorea, which, besides 
the perturbation of the nervous system, is so often attended with disor- 
ders of nutrition and of the functions of organic life. To put a stop 
to this state of languor, to re-establish at the same time the equilibrium 
of the movements, which are rather irregular than convulsive, to en- 
deavor, in fine, by regulating the contractions, to break up their vitiated 
habit, — this is the triple object sought to be attained by gymnastics. Be 
it theory or empiricism, success crowned these previsions, and proved 
the utility of the new treatment, of which we are about to study the 
methods and its consequences." M. See says, that to commence the 
treatment, we must prescribe first simple and cadenced movements, and 
exercise at the same time the larynx by means of singing. "To place 
the child in a vertical position, make it flex and extend the knees, touch 
the ground, stretch out and bend the arms, harmonizing at the same time 
these various movements by regulated singing, — such are the first means 
by which to replace the contractions under the power of the will. This 
end will be so much the more rapidly attained, as the attention of the 
patient is the less distracted, its intelligence the less changed, and its 
temper the less capricious ; so also is it often impossible to succeed unless 
we first obtain control over the patient by kindness and gentleness. 

"After reaching this point, we may attempt walking, regulated to a 
slow or quick step, running, jumping, hanging by the arms, or other more 
complicated movements, alwaj^s graduating them to the degree of the 
disease, watching them most carefully, and repeating them daily without 
prolonging them beyond fifteen or twenty-five minutes, in order to avoid 



568 CHOREA. 

muscular fatigue and palpitation of the heart, which occur sometimes 
when the exercises are too long continued. 

" With these precautions, and no matter how severe the sjmiptoms, we 
may, after a few lessons, and sometimes after the first, and at latest after 
the fifth or sixth, perceive a manifest change in the abnormal mobility, 
which is usually so rapid that we are generally able to decide, after the 
first eight days, as to the efficacy of the treatment. When, after this 
length of time, the patient can neither stand erect, walk in a straight line, 
nor hang by the arms, there is reason to fear that the method will fail ; 
it is at least certain that it will be tedious and difficult." 

In Banking's Abstract (loc. cit., p. 50) m&y be found the following 
statements in regard to the treatment by gjnnnastic exercises : 

They were first empkyyed under the guidance of M. Laisne, gymnastic 
professor of the Polytechnic School, their effects being tried first on scrof- 
ulous children. " Commencing with simple movements of the legs and 
arms, accompanied by appropriate songs, the children's progress was so 
rapid, that they were soon able to employ the orthopcedic ladder, the 
parallel bars, and other machinery, in succession. By the twentieth les- 
son they were exercised in wrestling, and afterwards in running, special 
exercises being devised for the lame. From the first lesson the children 
became fired with emulation, and movements which seemed impossible 
were soon executed with ease and pleasure. A marked amelioration was 
speedily observed, their countenances becoming animated, their flesh firm, 
their voices stronger, their appetite keener and more regular ; glandular 
swellings, which had long resisted all treatment, were resolved, and fistu- 
lous sores, that had been open for years, closed up. The lessons, one hour 
each, were given three times a week ; and in the intervals the children 
amused themselves by repeating such of them as did not require ma- 
chinery." This treatment, at first applied to scrofulous children, was, as 
stated above, extended to those laboring under nervous affections, partial 
paralysis, rickets, and especially chorea. Since 1847, ninety-five children 
suffering from chorea, sometimes so obstinate as to have resisted the most 
various treatment, have been cured b}^ this means alone, or in conjunction 
with others, and no accident has resulted from the employment of the ex- 
ercises. The movements are graduated according to the severity of the 
case, and they are repeated daily, but not for more than from fifteen to 
twenty-five minutes, so as not to induce fatigue or palpitation. "Im- 
provement is sometimes seen after the first lesson, and at latest after the 
fifth or sixth ; so that at the end of a week we can judge whether the 
means are likely to prove efficacious, and if manifest improvement has 
not then taken place, it is doubtful whether the cure will be thus effected, 
or if it is, it will be so only after a long time. The worst as well as the 
slightest cases have reaped equal benefit, the cure in the favorable ones 
only requiring a mean of twenty-nine clays, and old or relapsed chorea 
being more amenable than recent. Dr. See has found that when other 
remedies are conjoined with the gymnastics, the proportion of cures is 
less, and the period of their attainment later ; and he recommends no 



ATROPHIC INFANTILE PARALYSIS. 569 

other adjunct to be employed than good diet." (Dr. See on Chorea, loc. 
cit., No. 16, p. 50.) 

Hygienic Treatment. — The management of the hygiene of the patient 
is quite as important as an}- other part of the treatment. The diet should 
be arranged to suit the particular condition of the individual, and with a 
view to procure and maintain the most healthful possible state of the 
digestive apparatus. It should always be light and easily digestible, in 
order that neither the stomach nor bowels may be oppressed and deranged 
by the products of an imperfect digestion. When the stomach is weak 
and dyspeptic, the food ought to consist for some days chiefly of prepara- 
tions of milk and bread, whilst in the meantime, a tonic remedy is admin- 
istered internally, in order to invigorate the power of that organ. As 
the digestive function becomes stronger, the child ought, as a general 
rule, to be put upon the kind of diet most likely to promote the general 
health and vigor of bod}'. It ought to consist of bread, milk, plain whole- 
some meats, and simple vegetables. Coffee and tea, and all other nervous 
stimulants, had better be avoided. The meats ought to be mutton, beef, 
or poultry. There are few vegetables, besides rice and potatoes, which 
are suitable under the circumstances. All candies, preserves, unripe, 
coarse, or dried fruit, hot bread and cakes, except the very simplest, 
ought to be withheld. 

Of dress we need nierety saj^ that it must be suited to the season. Ex- 
ercise, or at least, exposure to fresh air and insolation, are of the utmost 
consequence. When the disease is so violent as to prevent the child from 
walking, it ought to be taken to drive as often as possible. In cases 
which seem connected with a debilitated and anremical condition of the 
constitution, removal to the country, and particularly to the seaside, will 
often effect a cure with great rapidity. Whenever, indeed, a patient in- 
habiting a large city or town can be conveniently taken to the seaside in 
the summer, it ought to be done, for the change is useful not only at the 
time, but it lessens, also, by strengthening and invigorating the constitu- 
tion for the future, the danger of a relapse. 



AETICLE XI. 

ATROPHIC INFANTILE PARALYSIS. 

Paralysis in the young child, though occasionally met with in most of 
the forms observed in the adult, most frequently presents itself in a form 
almost peculiar to childhood, characterized by total or partial loss of power 
over one or several groups of muscles, usually without impairment of sen- 
sation, and often followed by atrophy of the palsied muscles, and conse- 
quent deformities. 

History and Synonymes. — Occasional allusions to infantile paralysis 
may be met with in medical writings even as far back as the latter part 



570 ATROPHIC INFANTILE PARALYSIS. 

of the Inst century, but of such a vague and indefinite nature that the full 
recognition and accurate description of this peculiar affection cannot be 
said to date further back than the writings of Kenned}' and Heine, in 
1836 and 1840 respectively. Since the publication of Heine's classical 
memoir, however, a number of observers have studied the disease with 
much attention and success. We have subjoined a list of the principal 
writings upon this subject to which we have been able to obtain access. 1 

1 Bibliography. — Underwood, Treatise on Diseases of Children, London, 1789. 

Eostan, Reeh. sur le Eamoll. du Cerveau, 2eme ed., Paris, 1823, obs. L. 

Shaw, on Nature and Treatment' of Distortions, London, 1823. 

Cazauvieilh, Arch. Gen. de Med., t. xiv, 1827, pp. 5 and 347; Eech. sur l'Agen- 
isie et la Paral. Congeniale. 

Badhain, London Medical and Surgical Journal, 1835. 

Kennedy, Observations on Apoplexy and Paralysis of New-born Infants; Dublin 
Jour. Med. Scien., 1836 ; and Dublin Med. Press, 1841 ; and Dublin Quart. Jour, of 
Med., 1850, and Nov., 1861. . 

Marshall Hall, Lect. on Nervous System, London, 1836, p. 81. 

Heine, Beobach. ii. Lahmungszustande der untern Extremitaten und deren Be- 
handlung, Stuttgart, 1840; and, Spinale Kinder Lahmung, Stuttgart, I860, see Can- 
statt's Jahr., vol. iii, p. 70, 1860; and Med. Times and Gaz., London, 1863. 

Graves's Clinical Med., 1843, p. 409. 

Colmer, London Med. Gaz., April 21, 1843. 

McCormac, Lancet, May 27, 1843. 

E. Doherty, Dublin Med. Jour., vol. xxv, 1844, p. 82. 

"West, Lect. on Dis. of Childhood, London, 1848. 

Eichard (de Nancy), Bull, de Ther., Fevr., 1849, p. 120. 

Fliess, Jour. f. Kinderkr., July and August, 1849. 

Bellingham, Dublin Med. Press, 1850. 

Eilliet, Gaz. Med. de Paris, Nov., 1851. 

"W. Gull, on Paralysis during Dentition, in article on Yalue of Electricity as a 
Eemedial Agent, Guy's Hosp. Eep., 2d ser., vol. viii, pt. i, 1852, p. 81. 

Little, on Deformities of Human Frame, London, 1853, p. 120. 

Eilliet and Barthez, Traite des Mai. des Enfants, ed. 2eme, 1854, t. ii, p. 545. 

Yogt, Essential Paralj-sis of Children, Berne, 1858, pp. 86; New York Journal of 
Med., Jan., 1859, p. 117. 

Eulenberg, on Essential Paralysis of Children, Yirch. Arch., 1859, 177; and 
Schmidt's Jahrb., vol. 107, p. 55. 

Bierbaum, Paralysis of Children, Jour. f. Kind., 1859, 1 and 2, p. 18. 

Copland, Diet, of Pract. Med., vol. iii, Amer. ed., 1859, p. 24. 

Yalleix, Guide du Medicin Pract., ed. 4eme, 1860, t. i, p. 759. 

Brunniche, ii. d. sogenannt. Essentiellen Lahmungen bei Kleinen Kindern., Jour, 
f. Kind., 1861. 

Echeverria, Atrophic Fatty Palsy in Infancy, Amer. Med. Times, July 13, 1861. 

Chassaignac, a Peculiar Form of Infantile Paralysis, Med. Times and Gaz., Nov. 
9, 1861. 

Duchenne, De l'Electrisation Localisee, Paris, 1861, p. 275. 

Smith, Paraplegia occurring in Young Children, induced by wet and cold, Lan- 
cet, 1861. 

Bouchut, Des Maladies des Nouveaux-nes, &c.,ed. 4eme, Paris, 1862, p. 122. 

Laborde, De la Paralysie (dite Essentielle) de l'Enfance, These de Paris, 1864. 

Jaccoud, Des Paraplegies, &c, Paris, 1864, p. 448. 

W. A. Hammond, on Organic Infantile Paralysis, New York Med. Jour., Dec, 
1865, p. 168; and Jour, of Psych. Med., vol. i, 1867, p. 49, and vol. ii, 1868, p. 531. 

Adams, on Club-Foot, London, 1866. 



CAUSES. 571 

It will be observed that the vague and discordant views which have been 
held in regard to its cause and nature, have led to the employment of 
many names by which to designate it. Thus it has been called by Heine 
infantile spinal paralysis, and Meyer follows him in the use of this term; 
by Gull it was called paralysis during dentition; by Billiet and Barthez, 
Yogt, Eulenberg, Yalleix, Brunniche, Laborcle, and Niemeyer, essential 
paralysis of children ; by Duchenne, who is followed by Echeverria, fatty 
atrophic paralysis of infancy; by Rejmolds, paralysis with wasting of the 
muscles ; by Bouchut, nrvogenic paralysis ; by Hammond, organic infan- 
tile paralysis ; and it has also been called idiopathic and congestive in- 
fantile paralysis. 

We have been led to select the name which heads this article, because 
those above enumerated appear to us to be either vague and inaccurate, 
as the terms essential and idiopathic ; or to neglect the most striking fea- 
ture of the disease, the muscular atroph}^, as the term infantile spinal 
paralysis does ; or to convey a partial or even erroneous theory of the 
pathology of the disease, as the names congestive and myogenic respect- 
ively do. The terms organic and fatty atrophic paralysis also seem to us 
defective, since the first is equally applicable to cases of palsy due to or- 
ganic disease of the brain, while the second is based upon the fatty de- 
generation of the affected muscles, which, however, occurs only in a por- 
tion of the cases of infantile paralysis. 

Causes. — The etiology of this affection is very obscure, doubtless 
partly owing to the fact that, as the paralysis occurs when the spinal 
system is extremely impressible, the causes which induce it are trivial 
and usuall} T entirely overlooked. Age is the only influence which can be 
said to have a positive action in its production, since the great majority 
of cases occur between the ages of six months and two years, during the 
period of primary dentition. By several of the early observers especially, 
the disease was on this account attributed solely to dental irritation, but 
more careful observation shows that in most cases no such direct connec- 
tion can be traced; and it is probable that early age and dentition only 
act indirectly by inducing a remarkably susceptible condition of the entire 
spinal system. 

Sex appears to have no influence whatever upon its production; and 
the disease is almost as frequent among the children of the wealthy as 
among the illy fed and illy tended children of the poor. In some few 
cases, where the loss of power is sudden, the exciting cause seems to 



C. Handfield Jones, Functional Nervous Dis. (Amer. ed.), Philada., 1867, p. 88. 

J. Kussell Eeynolds, Lancet, vol. ii, July 11, 1868, p. 35. 

C. B. Eadcliffe, Art. on Infantile Paralysis, Eeynolds's Syst. of Med., vol. ii, 1868, 
p. 661. 

T. Hillier, Diseases of Children (Amer ed.), Phila., 1868, p. 255. 

S. TVilks, Lect. on Nerv. Dis., Med. Times and Gaz., Dec. 19, 1868, p. 689. 

Moritz Meyer, Electricity in Practical Medicine (translated by W. A. Hammond, 
M.D.), New York, 1869, p. 218. 

Niemeyer, Practical Medicine (Amer. ed.), New York, 1869, vol. ii, p. 338. 

Vogel, Diseases of Children (Amer. ed.), New York, 1870, p. 391. 



572 ATROPHIC INFANTILE PARALYSIS. 

be the direct exposure to the local action of cold, as from sitting upon a 
stone step (West). 

Atrophic infantile paralysis is usually primary, and occurs in the midst 
of good health; but it has also been observed in a secondary form, appear- 
ing during the convalescence from measles, scarlatina, or typhoid fever, 
or during rheumatism and chorea. 

In one of the cases following chorea, which are recorded by Kennedy 
(Joe. czY.), it is positively stated that there was a distinct cardiac murmur, 
due to organic valvular disease ; and it may be suggested that the essen- 
tial cause of the paralysis was embolism of some of the spinal arteries, as 
observed by Panum. 1 

Mode oe Attack; Initiatory Symptoms. — There is considerable 
variety in the mode in which this disease makes its appearance. In some 
cases the paralysis is the first s3 T mptom observed, and is found to have 
almost immediately attained its full extent, without any recognizable 
cause or premonitory symptom. Thus the child may have appeared per- 
fectly well when put to bed in the evening, and yet on the following morn- 
ing, there rnay be more or less complete loss of power over the lower ex- 
tremities. But in the great majority of cases, especially the more severe 
ones, the attack is preceded by quite marked constitutional disturbance. 
This may consist merely of fever, appearing without evident cause and 
lasting from a few hours to a week or more, unattended b} r an}' gastro- 
intestinal disturbance. Or, during this period, the child ma} T also com- 
plain of pain in the back, or there ma} 7 be tenderness on pressure, especi- 
ally in the lumbar region ; there is frequently slight dulness of the mind, 
or finally, in comparatively rare cases, one or more convulsions ma} T occur. 
It is the rule, however, for no marked symptoms of cerebral disturbance 
to be present at any period of the disease. There are rarely am- symp- 
toms connected with the parts about to become paralyzed, though in an 
interesting case recorded by Kennedy (loc. czY.), there was spasm of the 
muscles subsequently affected. 

The disease usually makes its appearance during health, but it is prob- 
able that many of the cases of paralysis occurring during convalescence 
from the various exanthemata property belong to this variety. 

Whether preceded by initiatory s3 T mptoms or not, the development of 
the paratysis is generally sudden, and it is onty in rare cases that it is 
partial at first and increases gradually. Indeed it usually happens that 
when first observed the paratysis is at its maximum, both as regards the 
number of muscles affected and the degree of the loss of power, and that 
there soon occurs a diminution in its extent, so that onty some of the 
parts first affected remain palsied. 

The form of the paralysis clearty indicates its spinal origin. Complete 
hemiplegia is scarcely ever observed, though in a few cases the arm and leg 
of the same side, or even all four extremities, have been palsied. 2 Most fre- 

1 Ueber den Tod durch Embolie (Bibliothek fur Lager, 1856), quoted by Jaccoud 
(op. cit., p. 297). 

2 With reference to the parts affected, in 43 cases observed and analyzed by West, 



MUSCLES AFFECTED — SYMPTOMS. 573 

qnently the disease takes the form of incomplete paraplegia, though occa- 
sionally the paralysis affects single groups of muscles or even individual 
muscles. 

According to Mr. Adams, the groups of muscles most frequently 
affected are: 1. The muscles of the anterior parts of the leg forming the 
extensors of the toes and the flexors of the foot; 2. The extensors and 
supinators of the hand, these muscles being always affected together; 
and 3. The extensors of the leg, and with them generally the muscles of 
the foot, as in the first group. When single muscles are affected, the 
most likely to suffer are these: 1. The extensor longus digitorum of the 
toes; 2. The tibialis anticus; 3. The deltoid; and 4. The sterno-mastoid. 

The bladder and rectum are very rarely involved. 

The degree of paralysis varies as much as its extent ; usually complete 
at first, in some cases it soon becomes partial or even slight ; while in 
others the loss of power remains absolutely complete. The paralyzed 
muscles are perfectly relaxed, so that the affected parts can have all their 
normal movements impressed upon them without difficulty, and fall in a 
lifeless manner if left unsupported. The special senses are unimpaired ; 
and general sensibility is usually only blunted for a time. Occasionally 
it is not affected at all, or, as stated by West, there may even be hyper- 
esthesia for a variable time. 

The paralyzed muscles are rarely the seat either of painful subjective 
sensations or of tenderness on pressure ; though in some cases severe 
pain ma}' be present in the affected parts. 

Reflex movements are, as a rule, abolished in those parts where there is 
complete loss of voluntary motion ; though Laborde (loc. cit.) has shown 
that the}^ may occasionally be preserved even in the first stage of the pa- 
ralysis. 

During the early stage we are at present considering, the electro-mus- 
cular contractility usually remains intact, and the muscles respond both 
to the induced and direct current. 

The constitutional disturbances which we have described as preceding 
the paralysis, may persist for a variable time after its development, or 
disappear quickly, leaving no other symptoms present but those con- 
nected with the paralyzed parts. 

The following case, seen by one of ourselves with Dr. James Tyson, 
may be quoted as an illustration of this form of paralysis: 

A male child, set. thirteen months, was brought to Dr. Tyson for treat- 
in only 2 was the arm alone palsied, though in 19 instances the paralysis was limited 
to one or both legs. In 8 cases the right leg, and in 5 the left, was paralyzed; and 
in one of the former instances paralysis of the right portio dura was also present. In 
6 instances, the right arm and leg, and in 8 the left arm and leg, were affected, with 
which ptosis of the left eyelid was once associated, and once paralysis of the left portio 
dura. Paraplegia existed in 8 instances, combined in one case with paralysis of the 
right arm, and in another with loss of power over both deltoid muscles, and over the 
flexor muscles of both thumbs. Six times none of the limbs were palsied, but the affec- 
tion was confined once to the portio dura of the left, and five times to the portio dura 
of the right side ; but in one of these instances, though there was no actual paralysis, 
the patient's gait was feeble and tottering. 



574 ATROPHIC INFANTILE PAEALYSIS. 

ment by its mother, an intelligent woman, with several health}' children. 
The following history of the case was obtained : The little boy had walked 
at the age of nine months, and alwa}'s seemed a vigorous, intelligent child ; 
he had also cut eight teeth, without much irritation. About Sept. 10th, 
1868, after no particular exposure, he became fretful and feverish, with 
occasional vomiting ; and after three da}~s it was noticed that right-sided 
hemiplegia had developed itself. The paralysis of the arm was never com- 
plete, while the leg had entirely lost all power of motion. This loss of 
power had not become complete suddenly, but, at first partial, had grad- 
ually increased. There was no tendency to coma and no evidence of any 
acute pain. The febrile symptoms soon disappeared ; the arm regained the 
power of motion in a few days, but the leg remained palsied. It also soon 
grew remarkably cold, and when seen on October 1st, three weeks after the 
attack, the temperature was decidedly lower than that of its fellow. Sen- 
sation was impaired, but had never been abolished. There had been no 
paralysis of either bladder or rectum. At the time of the examination, 
the child seemed bright and lively, though rather pale. There was no 
tenderness along the spine, nor in the leg. No reflex movements were 
developed in the paralyzed leg by tickling the sole of the foot. Neither 
atrophy or deformity had as yet occurred. 

The subsequent course of the disease varies greatly in different in- 
stances. In one set of cases, though the paralysis may be quite extensive 
and complete at first, the symptoms gradually subside, the paralysis dis- 
appears, and complete recovery ensues in from four to six weeks. These 
cases correspond exactly to the form of paralysis originally described by 
Kennedy (loc. cit.) under the name of "Temporary Infantile Paralysis," 
and, as we shall see hereafter, in all probability depend upon mere con- 
gestion of the spinal cord and meninges. 

In the other set of cases, on the contrary, the loss of power persists, 
and after it has continued for a time, varying from one to several months, 
is followed hy marked and more or less rapid atrophy of the affected 
muscles. The circulation in the paralyzed parts becomes feeble, the sub- 
cutaneous veins are smaller, and Heine, and Rilliet and Barthez each 
cite a case of paralysis of the arm in which it was almost impossible to 
detect the radial pulse. The temperature of the affected part becomes 
perceptibly lower, the fall amounting, according to Hammond, to from 5 
to 8 or even 10 degrees, as tested by a galvanometer. The muscles them- 
selves undergo marked atrophy, frequently accompanied by fatt}' degen- 
eration ; and their reflex motility and electro-muscular contractility dis- 
appear. It is important to notice, however, that long after muscular 
contractions fail to be produced b} 7 the induced current, the} r may fre- 
quently be excited by the use of a direct current of low tension, slowly 
interrupted. , 

The mere wasting of the muscles is not, however, the only cause of 
the great difference in size between the healthy and paralyzed members. 
The nutrition of the whole limb is affected, and the growth and develop- 
ment of all its tissues arrested, so that the paralyzed member becomes 
smaller in all its dimensions than its fellow. Rilliet and Barthez cite an 



ATROPHY AND DEFORMITY. 575 

example which they observed, to show to how remarkable a degree this 
conjoined atrophy and arrest of development may progress. The patient 
was a young girl who was seized with instantaneous paralysis of the right 
lower extremity ; and the following measurements show the degree of 
inequality which was produced b} T four years' continuance of the paralysis 
and arrest of development : 

Right leg. Left leg. 

1. From the great trochanter to the external malleolus, 49 cent. . 54 cent. 5 mill. 

2. From the patella to the malleolus, . . . 29 " . 32 " 

3. Length of foot from heel to great toe, . . . 14 " 3 mill. 18 " 

Five months previously, the following diminution in thickness of limbs 
was noticed : at three fingers' breadth above the patella, on left side, 20 
centimetres, 16 on right; at the middle of the thigh, on left side, 29 
centimetres, and 22 on right. The height of the child was 116 centi- 
metres. 

This wasting and pals} r of the muscles is associated with relaxation of 
the ligaments, and the combination of these causes induces many of the 
deformities observed in childhood. When the paralysis affects one side 
of the body chiefly, it indirectly leads to various lateral curvatures in the 
spinal column, probably from a want of symmetrical action in the muscles 
of the two sides. 

In cases of paralysis of the arms, the relaxation of the ligaments about 
the shoulder-joint and the atrophy of the deltoid allow the head of the 
humerus to drop out of the glenoid cavity, so as to produce even com- 
plete dislocation, with apparent elongation of the paralyzed limb to the 
extent of three-fourths of an inch (West). 

As the muscles of the lower extremities are far most frequently affected 
in this form of paralysis, we usually find the resulting deformities involv- 
ing the feet and legs, where they constitute the greater proportion of all 
cases of club-foot. According to Adams, " these deformities occur in the 
following order of frequency: 1. Talipes equinus; 2, equino-varus; 3, 
equino-valgus ; 4, calcaneus, or calcaneo-valgus ; and 5, talipes varus. 
When both feet are affected, equino-varus of one foot is generally found 
with equino-valgus of the other." 

In addition to the influence which the actual wasting of the limb and 
the arrest of its development exert, Adams believes the great cause of such 
deformities is the "adapted atrophy" of Paget, the changes which ensue 
in consequence of the mechanical relations of the foot to the leg. Al- 
though, however, it is true that paralysis of a group of muscles does not 
excite active contraction in their opponents, it appears that in the efforts 
of the child to move the part, the non-paralyzed muscles must gain con- 
trol over the limb, and aid at least in producing the various characteristic 
distortions. 

During the development of this atrophic stage, the general sensibility 
of the affected parts is usually normal, and the general health, intelli- 
gence, and nutrition of the patient unimpaired. 

Duration. — As will be inferred from our description of the course of 
this affection, the entire duration and that of its different stages varies 



576 ATROPHIC INFANTILE PARALYSIS. 

greatly in different cases. In some, which have hence had the name 
"temporary" infantile paralysis bestowed upon them, the loss of power 
rapidly diminishes, and complete recovery follows in from a few days to 
a few weeks ; while, in other cases, the paralysis persists until atrophy 
ensues, and the limb ma} T remain crippled and useless throughout life. The 
period which elapses before atrophy commences, and the rapidity with 
which it advances, also vary extremely, even in apparently similar cases. 
Thus the palsied muscles msij begin to atrophy within four or five weeks, 
though more frequently this change cannot be noticed for several months. 
Different muscles also atrophy with very different rapidity, the deltoid 
and tibialis anticus appearing to waste more rapidly than any other mus- 
cles of the body; and, in different cases, the same groups of muscles show 
equal variety in this respect, a few weeks serving in some instances for 
as much wasting to occur as would require months to produce in other 
cases. 

Prognosis. — The great uncertainty of the progress and duration of 
atrophic infantile paralysis render it highly desirable to ascertain, if pos- 
sible, the conditions which determine its result. Of itself, it is never 
fatal ; but, unfortunately, our prognosis is limited, in the early stage of 
the disease, to this assertion, for the duration and course of the case are 
not influenced, in any constant and reliable wa} T , either by the age of the 
patient, the extent of the paralysis or the parts affected, or the initiatory 
symptoms. It may perhaps be stated that, in general, cases which are 
ushered in by high fever, especially if associated with convulsions, and 
in which the paralysis is extensive, will prove severe aud tedious. But 
there are too many exceptions to every particular of this statement for it 
to be regarded as a general rule of much positive value in prognosis. 

When paralysis has lasted three or four weeks, we are able to deter- 
mine with much accuracy the approach of atrophy by the condition of the 
electro-muscular contractility ; for it has been frequently observed that 
those muscles which lose their power of responding to the interrupted 
current, soon begin to waste. 

After the occurrence of atrophy, also, much valuable aid in prognosis 
is gained from the use of electricity. 

We may here mention the interesting and highly important observa- 
tion, first made in connection with this disease by Hammond (loc. cit.) 
and J. Netten Kadcliffe, 1 that in many cases where the atrophied muscles 
have lost entirely their power of reacting to the most powerful induced 
electrical currents, they will still react vigorousty to a direct (galvanic) 
current of low tension and slowly interrupted. The importance of this 
discovery, in the treatment of the disease, can scarcely be overrated ; and 
it has also enabled this point to be established in the prognosis, that 
whenever muscular contractions can be excited by either induced or 
direct currents, no matter how far advanced the atrophy of the muscles, 
the restoration of their power can certainly be accomplished ; though it 
would appear from a case successfully treated by Hammond, that even 

1 See foot-note to page 665, vol. ii, Reynolds's System of Medicine. 



MORBID ANATOMY AND PATHOLOGY. 577 

when such contractions are not at first produced, the prognosis is not 
absolutely unfavorable. The still more curious, and as }-et inexplicable 
observation has also been frequently made, that as the muscles regain 
their power of voluntary motion, their susceptibility to the direct galvanic 
current is apt to diminish, but, on the other hand, their normal reaction 
to the induced current returns. 

The prognosis will also be materially influenced, especially when the 
atrophic stage has begun, hy the condition in which the tissue of the pal- 
sied muscles is found, as in cases where advanced fatty degeneration is 
present, it is far more unlikely that they will ever regain their power. 
In order to ascertain this point, Puchenne has devised a small trochar, 1 
called by him ; - emporte-piece," by which small pieces of muscle can 
be extracted, and subsequently submitted to microscopic examination. 

It is evident, finally, that the duration and result will depend, to a 
great extent, upon the period at which treatment is instituted. In those 
cases where the paralysis has been allowed to continue until marked 
atrophy has ensued, and the electro-muscular contractility is almost lost, 
although the prognosis may still be favorable as regards the ultimate cure, 
it must be carefully guarded as to the duration, since the treatment will 
probably require to be steadily pursued for many weeks, or even months. 

Morbid Anatoaiy and Pathology. — It appears desirable to introduce 
the consideration of the anatomical appearances at this point, in order to 
facilitate the subsequent discussion of the pathology and diagnosis of the 
disease. 

In regard to the changes which take place in the atrophied muscles, 
the brief yet complete summary given by Hillier, may be quoted (op. cit., 
page 268): 

" 1. The transverse striae become less apparent and separated by wider 
spaces, which are filled with opaque granules, which are not dissolved by 
ether, but are sensibly acted on by acetic acid. 

" 2. The transverse striae disappear, and there is an abundant appear- 
ance of granular substance. 

" 3. There remain but slight traces of longitudinal fibres, filled with 
granules, with a larger quantity of connective tissue between the bundles. 

" 4. The granules have disappeared, and empty transparent tubes of 
myolemma with a few scanty granules on their walls remain, with more 
connective tissue and some elastic fibres. 

" 5. In some cases, fat globules take the place of the granular matter 
in the muscular fibres, and in the cellular tissue between the bundles of 
muscular fibre. This change is not universally present in cases even 
when atrophy has proceeded to an extreme degree." 

The last conclusion stated here, which has been confirmed hy other 
observers, shows that perhaps the most frequent change which occurs, is 
a simple atrophy of the muscles, with a granular but non-fatty degenera- 

1 These trochars are manufactured by Tiemann, of New York. Dr. Hammond 
has published (Jour, of Psych. Med., July, 1867) a description of their form and 
mode of use, illustrated by a wood-cut. 

37 



578 ATROPHIC INFANTILE PARALYSIS. 

tion, and conclusively shows the inaccurac}^ of the name proposed by 
Dnchenne for the disease (nainety, fatt}^ atrophic paralysis of infants). 

In approaching the question of the lesions of the nervous centres in 
this affection, it is necessary to refer to the general question of the ex- 
istence of so-called essential, purely neurotic paralyses. In one form of 
paralvsis, the reflex, it is true that as yet no material lesion has been de- 
tected, and that the most plausible explanation of the loss of power in such 
cases is simply the exhaustion of the functional activhy of the spinal cord, 
owing to the prolonged irritation of some of the peripheral nerves. And 
it must be borne in mind that by some the form of infantile paralysis 
under consideration has been regarded as a reflex paralysis depending 
on dental irritation. Apart, however, from the fact, that the S}^mptoms 
much more closely resemble those due to spinal congestion than those 
seen in reflex paralvsis, it is to be remembered that the disease is b} T no 
means limited to the period of dentition, and that all local signs of dental 
irritation are frequently absent at the time of the appearance of the pa- 
ralvsis. With the exception then of reflex paralysis, it may be asserted 
with confidence that all other forms of spinal paralysis are associated 
with some material lesion of this nervous trunk. It is to be remembered 
that it is only a few years since the beautiful researches of J. Lockhart 
Clarke have shown that positive structural changes, in both nerve-cells 
and nerve-fibrils, inay be detected by microscopic examination in spinal 
cords, which present no alteration apparent to the naked eye. In reject- 
ing the evidence of all post-mortem examinations of the spinal cord, made 
before the introduction of Clarke's method, as incomplete and inconclu- 
sive, we find that in all those diseases formerly classed as pure neuroses, 
(such as tetanus and chorea) which have been subjected to this latter mode 
of examination, positive demonstrable lesions have been detected. 

Among this class of diseases, so long considered as purely functional 
neuroses, atrophic infantile paralysis has alwa3 T s, until lately, occupied a 
prominent position, as is evinced b} T the large number of authors who 
have described it under the terms "essential," or "idiopathic." 

It is indeed difficult to secure opportunities of examining the state of 
the spinal cord in this affection, owing to the fact that the disease is 
scarcely ever, if at all, fatal of itself; so that the arguments in opposition 
to the view of its functional nature, will be in part drawn from the close 
analogy of its s3 T mptoms to those of certain spinal diseases, which are 
well known- to be attended with positive lesions of the nervous tissue. 
Thus, in its mode of appearance, and in the character of the paralysis, 
there is so perfect a resemblance to the onset and symptoms of congestion 
of the spinal cord, as to leave little room for doubt that this is the condi- 
tion at first present in atrophic infantile paralysis. In both this affection 
and spinal congestion, the paralysis may appear quite abruptly, or be 
preceded by pains in the back and fever ; in both, the paralysis is usually 
paraplegic, the loss of power only partial, and the affected muscles are 
relaxed ; in both, general sensibilit}' is but slightly impaired, the bladder 
and rectum are not involved, and there are no disturbances of the cere- 
brum or special senses; in both, finally, recovery usually follows, if proper 
treatment be promptly instituted. 



MORBID ANATOMY AND PATHOLOGY. 579 

In those cases where the paralysis disappears within a few days or 
weeks, it has been supposed by various authors that the nature of the 
disease is entirely different from that of atrophic infantile paralysis ; but 
it appears to us highly unnecessary to complicate the question by such a 
supposition, since the temporary character of the paralysis is readily ac- 
counted for by supposing that the spinal congestion which produced it 
was slight and transient. 

It is quite possible also that in other cases the loss of power caused by 
more severe spinal congestion should persist until atrophy of the affected 
muscles ensued, and rendered the case more protracted. 

Indeed, some of the authors who most forcibly support the view of the 
pathology of this affection which we have given above, as Dr. C. B. Rad- 
cliffe (Joe. eit.), hold that the lesion of the cord does not advance beyond 
this stage of congestion. The evidence in support of this opinion is prin- 
cipally found in the result of post-mortem examinations, as those reported 
by Rilliet and Barthez, Fliess and Adams, where no lesions of the cord 
were detected. But in none of these cases does it appear that the careful 
and skilful microscopic examination, which is now recognized as neces- 
sary to detect some lesions of the nervous tissue, was performed ; so that 
we may feel at liberty to doubt the complete accurac} 7 of these autopsies. 
On the other hand, it certainly seems entirely consistent to suppose that 
in certain cases, where the congestion is unusually marked and prolonged, 
or where it is repeated, that a process of subacute inflammation should 
be excited, resulting in the formation of inflammatory products. 

The usual change which takes place in the spinal cord, under such cir- 
cumstances, is that described under the name " sclerosis," in which there 
is marked proliferation of the connective-tissue elements of the cord, with 
swelling and consequent pressure upon the nerve-tubules. In the subse- 
quent development of the new-formed connective tissue, it undergoes 
contraction, and induces atrophy of the compressed nerve-tubules. The 
portions of the spinal cord where this lesion exists, may either be atro- 
phied or retain their normal size, shape, and external appearance, but on 
transverse section, though the tissue is firm, certain parts of the white 
substance are seen to present a grayish, translucent appearance, differing 
noticeably, in well-marked cases of the lesion, from the opaque whiteness 
of the surrounding healthy tissue. In other instances, however, the 
change in color cannot be detected, and it is only by microscopic exami- 
nation that we can discover the increase in the connective tissue of the 
cord, and the atrophy of the nerve-tubules. 

This view of the nature. of the lesions in atrophic infantile paralysis,. 
was forcibly urged by Heine, in the last edition of his classical mono- 
graph on this subject (op. cit.), who based it merely upon an analysis of 
the symptoms, and it has since been adopted, by Jaccoud (loc. cit). It 
does not rest, however, solely upon such reasoning, for there have been 
a limited number of autopsies made in which the above-described lesions 
of sclerosis have been actually observed. 

Heine quotes three post-mortem examinations in support of this theory. 
One of these, quoted from Longet, was of a girl of eight years, with club- 



580 ATROPHIC INFANTILE PARALYSIS. 

foot on the right side, following an attack of paralysis, who died of variola ; 
and at the autopsy the muscles and nerves of the right leg were atrophied, 
and the anterior roots of the spinal nerves which make up the right 
sciatic nerve, were scarcely one-quarter the size of the corresponding 
roots on the left side. 

In the second case, quoted from Hutin, the subject was forty-five years 
old, had been paraplegic from the age of seven j-ears, and had consider- 
able deformity of the lower members ; at the autopsy, after death from 
dysentery, there was atrophy of the lower part of the spinal cord. 

The third observation quoted by Heine, has been quoted more fully 
from the original source {Trans, de la Soc. Med. de Berlin, Dec. 1th, 
1862) b} T Jaccoud {op. czY., p. 450). It was the autopsy of a child with 
paralytic club-foot, reported by Berencl and Remak, where the " spinal 
arachnoid was found thickened by inflammatory product, and exercising 
such pressure upon the cord, that when the false membranes were cut, 
the nervous tissue immediately protruded through the incision." 

Berend also reported {id. loc.) another observation upon a child four 
years old, who died paraplegic with contraction of the legs and feet. The 
autopsy was performed by Recklinghausen,who found tubercles in the cord. 
Hammond reports {Jour, of Psych. Med., vol. i, p. 51) a case where 
the paralysis affected the left leg, and had lasted four years, in which 
he found, upon post-mortem examinatiou, a cicatrix partly filled with 
clot, in the lower part of the dorsal region, in the left anterior column. 

Finally, in two cases of atrophic infantile paralysis recorded b} 7 Laborcle 
{op. cit.), the existence of sclerosis of the spinal cord was demonstrated 
positively, and described with great minuteness. According to his obser- 
vations, the change is especially seated in the .anterior columns of the 
cord, though it also involves, to a less degree, the lateral columns. These 
parts are more translucent than natural, and present a very appreciable 
grayish-rose tint to the naked eye. The consistence of the affected tracts 
is diminished, and upon microscopical examination there may be observed 
a marked proliferation of the elements of the connective tissue, the cells 
and nuclei being dispersed in the midst of a finely granular substance, in 
which there are fibrils of extreme tenuity. In the parts which are most 
affected the nervous tubules are either lost altogethei\ or they present a 
varicose appearance ; while the other portions of the spinal column pre- 
serve a perfect integrity. 

We have thus quoted all the autopsies we have been able to find, of 
cases of atrophic infantile paralysis in which lesions of the cord have 
been detected. 

If a general conclusion may be drawn from them, it would appear to 
be that, in many cases at least of infantile paralysis when the loss of 
power has been of long standing and attended with muscular atrophy, 
there are positive material lesions of the spinal cord ; that these lesions 
chiefly involve the antero-lateral columns of the cord, and are in most 
cases of such a kind as to produce pressure upon the nerve-tubules, and 
ultimately lead to their atrophy ; and that when this atrophy is not pro- 
duced by pressure from thickening of the meninges, or from tumors or 



DIAGNOSIS. 581 

clots in the substance of the cord, it is probably due to sclerosis of the 
anterior columns. 

Diagnosis. — There is but little danger of overlooking the nature of 
those cases where the paralysis appears quite suddenly in the midst of 
apparent good health, excepting in cases occurring in young children who 
have not yet learned to walk, and where the loss of power is limited to 
the lower extremities. In such instances the paralysis may be entirely 
overlooked by the parents or nurse for some time. So also in cases pre- 
ceded by constitutional disturbance, as there is nothing whatever charac- 
teristic in these premonitory s > ymptoms, it is quite possible to fail to 
recognize the presence of paralysis. It is well, therefore, whenever a 
child between six months and three years of age presents feverish s}^mp- 
tonis for which no apparent cause exists, to ascertain carefully whether 
there is any loss of power of its extremities. 

The diseases with which atrophic infantile paralysis is most likely to 
be confounded, are other forms of paralysis of cerebral or spinal origin, 
and progressive muscular atrophy. 

In paralysis due to hemorrhage into the substance of the brain (see 
page 479), the case is more apt to be ushered in by delirium or convul- 
sions, followed b}^ more or less marked coma, while in atrophic infan- 
tile paralysis there is either entire absence of cerebral symptoms, or at 
most a single convulsion occurs. Cerebral paralysis is usually hemiplegic, 
while in the form of spinal paralysis we are considering, paraplegia is 
more common, or the loss of power may be limited to one leg or to a 
single group of muscles. In those comparatively rare cases where the 
parah'sis is at first hemiplegic, the arm usually soon regains its power of 
motion, leaving the leg paralyzed ; while the reverse of this occurs in cere- 
bral hemiplegia, where the leg usually improves much more rapidly than 
the arm. In cerebral paralysis, also, the affected muscles are frequently 
rigid instead of being relaxed; and there is not the tendency to atrophy 
and deformity, the loss of electro-muscular contractility, nor the lowering 
of the temperature of the affected part, which are observed in atrophic 
infantile paralysis. 

In cases of meningeal apoplexy where the hemorrhage has occurred 
upon the surface of the brain, the symptoms are still more distinct. Thus 
(see page 480) there are usually repeated convulsive seizures, with som- 
nolence during the intervals : paralysis is rare and partial, while strabis- 
mus and tonic contraction of the hands and feet are very common. 

In acute inflammation of the spinal cord, or myelitis, the loss of power 
is complete, and there is also more marked loss of sensation, and paralysis 
of the rectum and bladder, with alkaline urine; though there is here as 
well as in atrophic infantile paralysis, diminution of reflex excitability 
and electro-muscular contractility, and wasting of the paralyzed muscles. 
The symptoms first mentioned, the more grave character of the case, and 
the tendency of the paralysis to increase rather than decrease, suffice to 
distinguish myelitis from the affection under consideration. 

Progressive muscular atrophy, of very rare occurrence in childen, may 
be distinguished by its gradually progressive course ; and by the preserva- 



582 ATROPHIC INFANTILE PAEALYSIS. 

tion of the temperature of the affected parts, of the power of motion, and 
of electro-muscular contractility, until atrophy has far advanced. There is 
usually a quivering of the atrophied muscles in this disease, due to fibril- 
lar contraction, which is entirely wanting in atrophic infantile paralysis. 

We have already expressed our belief that some of the cases where the 
loss of power is very teniporaiy, are really instances of reflex paralysis, 
and in such some source of peripheral irritation can usually be detected. 

West alludes to the fact that in those cases where the affection is lim- 
ited to one leg, and attended by Irypersesthesia and painful sensations, 
the disease may be mistaken for coxalgia, though the diagnosis may 
readily be made by attending to the slow course, the absence of paraly- 
sis, the fixed pain in the knee-joint, and the marked increase of suffering 
caused by forcing the head of the femur against the acetabulum, which 
characterize hip-disease. 

Treatment. — The treatment of atrophic infantile paralysis may be di- 
vided into that adapted to the early stage and that directed against the 
second stage or period of atrophj\ 

In the first instance we must endeavor to discover and remove any 
exciting cause of the paralysis that may exist. If sjunptoms of morbid 
dentition have preceded, and the appearance of the gums indicate it, they 
should be lanced ; or if gastro-intestinal disturbance is present, or the 
presence of worms is suspected, laxatives should be administered. Tepid 
baths are also recommended, as tending to allay irritation and reduce 
feverishness. 

When, however, no local irritation can be detected to render it possible 
that the case is one of reflex paralysis, we should direct our remedies to- 
wards relieving the spinal congestion which we believe to exist in cases 
of true atrophic infantile paralysis. Counter-irritation should be applied 
along the spine, and may be effected by producing a narrow blister, or 
preferably by the use of sinapisms or stimulating liniments, containing 
croton oil, ammonia, or turpentine. 

Local abstraction of blood by means of cups or leeches applied along 
the spine has been recommended by Fliess ; and we should certainly advise 
its employment, especially in those cases where there is considerable 
febrile disturbance and pain in the back. 

There are also certain remedies from which we have obtained excellent 
results in the treatment of spinal congestion in the adult, and should, 
therefore, recommend their employment in the early stage of this affection. 

These are ergot, which maj^ be given in the form of fluid extract, begin- 
ning with doses of about 5 minims for a child of two 3 T ears old ; and bel- 
ladonna, which may be given either in the form of tincture, or an aque- 
ous solution of the extract. Iodide of potassium may also be given in 
combination with one or the other of these, in doses of gr. i or ii for a 
child of two years old, in the hope of preventing the development of any 
inflammatory changes in the cord. 

In addition to these remedial measures, the child should be absolutely 
confined to bed. 

If, despite the use of these agents, the paralysis persists, the tempera- 



TREATMENT — ELECTRICITY. 583 

ture begins to fall, and the muscles to atrophy, eveiy means must be 
adopted to promote the general nutrition of the child so as to favorably 
influence indirectly the changes in the spinal cord ; and at the same time 
local treatment must be instituted to promote the circulation and nutri- 
tion of the paralyzed parts. 

Among the internal remedies, iron is one of the most suitable, and may 
be given in any eligible form. The pjTophosphate is perhaps especially 
indicated on account of the phosphoric acid with which the iron is com- 
bined. 

The various preparations of mix vomica or its alkaloid strychnia are 
also very valuable after the acute stage has passed. Heine advises the 
use of tr. nucis vomicae in combination with camphor and pyrethrum ; 
while "West recommends the alcoholic extract of nux vomica. Strychnia, 
which is more frequently employed than the preparations of nux vomica 
itself, is usually given in the form of solution. Hillier has also used it 
hypodermically, but without marked benefit. 

The doses of these powerful drugs, which are recommended by some 
authors, especially Heine, appear to us too large to be safely administered. 

We should recommend beginning with a dose of at most gtt. ii of the 
tincture, or gr. Vyth of the alcoholic extract of nux vomica, or gr. ^th of 
sulphate of strychnia, for a child of two years old ; the amount being in- 
creased steadily but cautious^ so long as no unpleasant symptoms are 
produced by it. 

Local means must also be employed for inducing increased circulation 
in the affected parts. For this purpose, the stimulating liniments already 
mentioned, or moist heat, may be applied. Passive motion, and knead- 
ing the muscles, also aid in improving their nutrition and contractile 
power. 

Electricity, however, certainly ranks first among the local means for 
restoring the contractile power of the paralyzed muscles. It is true that 
several authorities have asserted that they derived no good results from 
its employment, but since the introduction of localized galvanism (fara- 
dization), as developed by the researches of Duchenne, and of the use of 
the direct current, the most marked benefit has been obtained at all stages 
of this form of paralysis. 

If the induced current be used, it must be carefully isolated and limited 
to the affected muscles, by means of wet sponges fastened to the elec- 
trodes. In those cases where the muscles refuse to respond to an induced 
current even of considerable power, the direct current, slowly interrupted 
(the labile current of Remak), will be found to induce contractions, ex- 
cepting where the muscular tissue is far advanced in fatty degeneration. 
In all such cases then, this direct current should be employed. We have 
already alluded to the curious observation which has been made by sev- 
eral authors, that as the palsied muscles regain their power under the use 
of the direct current, they respond to it less and less strongly, while the 
induced current is found to again have the power of exciting muscular 
contractions. When this period in the treatment of the case arrives, it 
is probably desirable to substitute the use of the induced current. 



584 ATKOPHIC INFANTILE PARALYSIS. 

In order that the use of electricity, in either form, may be productive 
of the excellent results it is capable of yielding, it must be applied thor- 
oughly to each of the paralyzed muscles three or four times weekly, and 
this treatment pursued for months, until the muscles regain both their 
size and contractile power. 1 

One of the earliest symptoms of improving nutrition is an elevation in 
the temperature of the part, which may readily be detected by the galvan- 
ometer, as before mentioned. The value of this mode of treatment is, 
indeed, so great " that so long as muscular contraction can be induced, 
recover}^ is merely a matter of time, but if no action of the paralyzed 
muscles can be brought about, the prognosis must be unfavorable, though 
even here there is some hope." (Hammond, Radcliffe.) 

In addition, however, to the local and general measures above recom- 
mended, there is another kind of treatment scarcely less important, which 
should be employed in conjunction with them. 

This consists in the use of such mechanical apparatus and gjmmastic 
exercises as shall tend to bring the affected muscles into pla}^, and to ob- 
viate the deformities of the atrophic period. The greater part of our 
knowledge upon this subject, is due to the admirable and extensive ob- 
servations of Heine, who has the superintendence of a large orthopceclic 
institute, and has most carefully studied the effects of these agents upon 
cases of paralysis which have progressed to the stage of atrophy and de- 
formity. But it is hy no means to this advanced stage alone that such 
measures are adapted, for it is a matter of the highest importance, that 
from a very early period of the paralysis, the little patients should be 
subjected to this treatment. 

If the legs be affected, it is not surprising that the child, who has, per- 
haps, gained but imperfect use of its limbs, and is making its first essays 
in walking when the paralysis appears, should feel such a sense of inse- 
curhVy, even when the power of motion has returned to a considerable ex- 
tent, that it will refuse to make any renewed efforts to walk. And the 
parents, finding all their attempts to persuade or compel it to do so una- 
vailing and distressing to the child, are apt to desist, waiting until in- 
creased power of movement returns : a delay which is too often followed 
by all the steps of the atrophic period. 

To supply the indispensable exercise of the muscles, and in a form at- 
tractive to the little patients, numerous mechanical contrivances have 
been resorted to. 



1 For a full description of the best forms of electrical batteries for medical pur- 
poses, the reader is referred to Meyer's work on " Electricity in its Relations to Prac- 
tical Medicine," translated by Hammond (New York, 1869). Among the best and 
most convenient forms of both induction and direct-current batteries, are those made 
by Stohrer, of Dresden, which can be had from his agent in London, J. F. Pratt, 420 
Oxford Street. There are also several induction-current batteries, of portable size 
and quite reliable and powerful, which are imported from Paris, and can be had at 
the stores of our electricians. 

Among batteries of American make, those of Kidder, Hall, and Drescher are the 
most convenient and reliable. 



GYMNASTIC AND MECHANICAL TKEATMENT. 585 

While the legs are still almost powerless, some form of baby-jumper at 
the same time delights the child and effectual^ exercises its limbs. When 
the power of motiou has returned to a somewhat greater extent, we gain 
the same results even more completely by the use of the go-cart or veloci- 
pede, a frame or a chair upon wheels, the motive power being furnished 
by the alternate pressure of the rider's feet upon a pair of treadles which 
are connected with the wheels hy cranks. This imparts such a sense of 
security and so much pleasure, that the child can readily be encouraged 
to take enough exercise to preserve the play of the articulations, and to 
aid in developing muscular power. 

Dr. West makes a single objection to the use of the go-cart; that it en- 
courages the tendency to lean very much forward in walking, which always 
exists until after the little patients have learned to walk pretty well; he, 
therefore, advises after the child has gained some facility in the use of the 
go-cart, that a jacket should be worn, supplied with a stout strap before 
and behind, so that the attendant can conveniently hold them and sup- 
port the child's weight more or less completely, thus enabling it to walk 
without being thrown forward as when stepping in a go-cart. 

In children of from five to seven years even, the use of crutches is soon 
acquired, and it is desirable, so soon as possible, to abandon the other 
contrivances spoken of, and trust the child to its own exertions to walk 
with a pair of crutches. 

When the paralysis affects the arms, precisely the same principle should 
guide us, and every form of persuasion, of stratagem, and contrivance, 
must be used to induce the child to exercise the crippled member. Trun- 
dling a hoop, or raising a weight by means of a cord passing over a pulley, 
furnish good exercise to the arm ; or we may encourage the little one to 
use a contrivance, also called a velocipede, in which the wheels, are turned 
by handles, instead of treadles, attached to the cranks. 

In addition to these forms of exercise, however, it is often found neces- 
sary to employ splints of different kinds, such as Stromeyer's, which ena- 
bles the angle of the splint to be changed without removal from the limb, 
and various modes of extension to counteract the tendency which exists 
to contraction of the paralyzed part. In some cases, indeed, all means 
are powerless to avoid this consequence, and we are obliged to resort to 
the section of the tendons of the contracted muscles and subsequent ex- 
tension, though tenotomy should not be performed until time has been 
allowed to show the extent of permanent paralysis, and until the conjoined 
use of electricity and orthopcedic apparatus has proved insufficient to re- 
store the limb to its shape. 

It may readily be surmised that this orthopcedic plan of treatment is 
one requiring the utmost patience and persistence, and the most loving- 
persuasion and encouragement ; for, indeed, it must be pursued, in face 
of all apparent failure, for months and years. Nor must we be satisfied 
during this period with these efforts we are making to restore the 
power of the muscles ; but careful attention must be paid to the nutrition 
and general health of the child, and we must continue the use of the warm 



586 FACIAL PARALYSIS. 

douche, in conjunction with the persistent use of electricity, of stimu- 
lating frictions, and of every remedy calculated to promote the general 
nutrition of the child. 



AETICLE XII. 



FACIAL PARALYSIS. 



Paralysis of the muscles supplied with motor power by the facial 
nerve, is frequently met with as a temporary condition in infants who 
have been delivered by forceps, as a result of the pressure of the blade of 
the instrument upon the nerve as it emerges from the cranium. It is 
b}^ no means rare, however, during childhood, and either appears sud- 
denly after exposure to cold, when it is possibly due to pressure caused 
by congestion and swelling of the tissues around the stylo-mastoid for- 
amen ; or more gradually, when it is usually due to pressure from an 
enlarged gland, or to disease of the petrous portion of the temporal bone. 

The symptoms of this affection are so striking that no difficulty can 
exist as to its diagnosis. The eye upon the affected side remains open; 
the power of knitting the forehead and of raising the eyebrow is lost ; 
the angle of the nose and mouth on the same side hang down. The tears 
trickle over the cheek, and the conjunctiva frequently becomes injected 
or inflamed ; saliva dribbles from the mouth, portions of food collect be- 
tween the teeth and paralyzed cheek, and there is inability to whistle, 
spit, or distend the cheeks with air. During the acts of laughing or cry- 
ing, the face becomes distorted, owing to the immobility of the paralyzed 
side, while the antagonistic muscles act strongly and draw the features 
towards the sound side. 

In cases due to an affection of the nerve in its course through the 
petrous portion of the temporal bone, usually depending upon caries or 
necrosis of this bone, there are present, besides the S3 T mptoms above men- 
tioned, purulent otorrhcea, deafness, diminution in taste on the side of 
the tongue corresponding to the paralysis, and in some cases unilateral 
paralysis of the velum palati. 

The possibility of mistaking simple facial paralysis for hemiplegia from 
cerebral hemorrhage must be borne in mind, though attention to the S} 7 mp- 
toms of the case will prevent any error in diagnosis. Thus in hemiplegia 
of cerebral origin, the paralysis is usually ushered in by convulsions and 
coma ; the frontalis and orbicularis muscles are not paralyzed ; but, on the 
other hand, the masseters, temporals, and pterygoids, supplied by the fifth 
nerve, occasionally are, and the tongue is protruded towards the para- 
lyzed side ; and, finally, there is loss of power in the arm and leg on the 
same side. 

The prognosis of cases of facial palsy must evidently depend upon the 
cause. When the paralysis is due simply to exposure to cold, a cure may 



PROGRESSIVE PARALYSIS. 587 

be expected, though the affection is often very tedious, the paralysis at 
times persisting for months. But when, on the other hand, it depends 
upon disease of the temporal hone, the prognosis is usually unfavorable. 

The treatment must also be modified according to the cause of the 
attack. 

In simple acute cases, the application of hot fomentations to the part, 
or of one or two leeches near the st} r lo-mastoid foramen, should always 
be directed, and is often productive of good results. Later in the affec- 
tion, if the paralysis persists, small blisters should be repeatedly applied 
over the point of exit of the nerve. 

Electricity is here also of very great service, and the same curious 
observation, which was mentioned in atrophic infantile paralysis, as to the 
power of the direct current to excite muscular contractions when the 
muscles have ceased entirely to respond to an induced current, has been 
frequently made in this affection (Baierlacher, Neumann, Radcliffe, 
Hillier). 

In addition to these local remedies, the internal use of strychnia, iron, 
or iodide of potassium, is often followed by benefit. In cases where there 
is reason to suspect that disease of the bone, or scrofulous enlargement 
of the cervical glands, are the cause of the paralysis, the patient should 
be put upon the use of iodide of iron or cod-liver oil. 



ARTICLE XIII. 

PROGRESSIVE PARALYSIS, WITH APPARENT HYPERTROPHY OF THE 

MUSCLES. 

Definition. — This disease occurs, so far as known, exclusively in chil- 
dren, and is characterized by progressive loss of power, advancing until 
nearly all the muscles of the body may be involved, while at the same 
time the affected muscles appear to increase in size from hypertrophy of 
their internbrillar fatty and connective tissue. 

History and Synonymes. — True progressive muscular atrophy is ex- 
tremely rare in children ; and among the cases which have been described, 
as by Meryon, 1 a certain number seem to belong to the curious disease 
now under consideration. The distinctive features of this latter affection 
were first recognized by Duchenne, 2 who has been studying it for more than 
ten years past. Cases have also been recorded by several authors, as by 
Eulenberg and Cohnheim, 3 Griesinger and Billroth, 4 Heller, 5 Seidel, Nie- 

1 Pract. and Path. Kesearches on Paralysis, London, 1864, p. 200, et seq. 

2 De l'Electrisation Localises, 2erne ed., Paris, 1861; and also a communication pre- 
sented in Duchenne's name by J. Lockhart Clarke to London Path. Soc. : sec Trans- 
actions, vol. xix, 1868, p. 6, with photographic illustrations. 

3 Verhandlungen der Berliner Medicinischen Gesellschaft, Hft. 2, 1866, p. 200. 

4 Yerhandl. der Berlin. Med. Gesellsch., vol. i, 1866, p. 101-205. 
6 Deutsche Arch. f. Klin. Med., vol. i, 616-627. 



588 PROGRESSIVE PARALYSIS. 

me} T er and Siegmund, 1 Benedikt, W. Adams, 2 and Hillier, 3 but as yet the 
literature of the subject is limited, and there are many points in connec- 
tion with the disease which are obscure. 

Various names have already been applied to the affection. It was 
originally called " hypertrophic paraplegia of infancy," by Duchenne, but 
he has since substituted the terms, paralysis with muscular degeneration 
(paralysie nwosclerosique), or paralysis with apparent lrypertroplry. It 
has also been called " lipomatosis luxurians musculorum progressiva ;" 
lipomatous muscular atrophy (Seiclel) ; progressive muscular paralysis, as 
a result of hypertrophy of the interstitial fatty tissue (Niemeyer). 

Causes. — The causes of this affection are entirely unknown. Age cer- 
tainly exerts a powerful influence upon its production, since the disease 
has as yet only been observed in childhood, and has even appeared in 
some cases to be congenital (Mender). 

Sex appears also to exercise a positive influence, for all the recorded 
cases have occurred in boys. The curious fact has also been observed 
that several children in the same family are apt to be affected, as though 
indicating some hereditary tendency. Apart from these general influ- 
ences, however, there is nothing known as to the cause of this form of 
paralysis. 

Symptoms. — The disease either begins in early infanc3 T , and is first 
manifested at the time the child should begin to walk, or it makes its ap- 
pearance some years after the power of walking has been acquired. 

The disease usually affects the muscles of the legs, and advances up- 
wards ; in xuemeyer's case, on the other hand, it began in the gluteal 
muscles, and subsequently affected all the muscles oi* the lower extremi- 
ties. The early symptoms are, therefore, connected with walking, and 
it is observed either that the child does not begin to walk until very late 
and then walks imperfectly, or that having walked well for several years, 
he begins to be readily tired by standing or walking, and soon presents 
peculiarities in his gait. When the disease is fully established, though 
before it has advanced far, the mode of walking and standing are quite 
characteristic. The patients find that, without some support, these opera- 
tions become more and more difficult and painful, and that they are sub- 
ject to frequent falls. In order to maintain their equilibrium while 
standing or walking, the lower dorsal and lumbar spine is arched forwards, 
while the upper part of the spine, the shoulders and head are bent back- 
wards, the legs are widely separated, and in walking the body is in- 
clined laterally towards the leg which rests on the ground, thus producing 
a characteristic balancing of the bod} 7 during progression. In Mender's 
case, " the patient could only walk, when, by aid of his arms, he had given 
his head and shoulders a position where their point of equilibrium fell 

1 Arch. f. Klin. Med., vol. i; and Niemeyer's Text-Book of Pract. Med. (Amer. 
Trans., 1869), vol. ii, p. 519. 

2 Trans, of Path. Soc. of London, vol. xix, 1868, p. 11. 

3 Trans, of Path. Soc. of London, vol. xix, 1868, p. 12 ; and Diseases of Children 
(Amer. ed.), 1868, p. 263. 



SYMPTOMS. 589 

behind the pelvis ; if this position were changed, he doubled forwards at 
the hip-joint." (Loc. dL~) 

While this impairment of progression is developing, the affected mus- 
cles undergo remarkable changes. These are thus described by Duchenne : 
" The second stage is usually announced some months, and even two years, 
after the beginning of the muscular weakness, by a progressive swelling 
or enlargement of the gastrocnemii, then of the glutei, and of the lumbar 
muscles of the spine. This apparent Irypertrophy occurs sometimes in 
nearly all the muscles which have been affected by parafysis, but in gen- 
eral it does not, and it may even be limited to a very small number of 
them. . . . The hypertrophied muscles are firm and elastic; they become 
very hard while they contract, and show all the relief or projection 
which properly belongs to their contracted state ; they then appear to 
form a hernial protrusion through the integument, which is very thin ; 
moreover, their great size shows off the apparent smallness and delicacy 
of the joints at the knee, ankle, &c." (Loc. cit.) 

The skin over the affected muscles may have a red, marbled appear- 
ance; the temperature of the part is lowered, and the power of voluntary 
contraction is greatly impaired, while the electro-muscular contractilhVy 
may either remain intact or be impaired. 

When this pseudo-hypertrophy is marked, and affects many muscles, it 
gives a most curious appearance to the children. Memeyer speaks of 
his patient as looking u as if he had the body and head of a weak child 
on the hips and thighs of a strong man ;" and J. Lockhart Clarke, in de- 
scribing one of Duchenne's patients, saj's: "He looked like a little Her- 
cules. Every visible muscle of the body, except the pectorals, was enor- 
mously developed; his head, even, appeared swollen, and the temporal 
muscles stood out like convex shells. Yet, when the poor boy attempted 
to walk, he labored to get along, presenting the most grotesque appear- 
ance ; and when laid on the ground, he was wholly unable to rise by his 
own unaided efforts." (Loc. cit., p. 9.) 

The disease may remain at this stage for several years, or even until a 
tolerably advanced period of \^outh, but finally it is succeeded by a stage 
in which the loss of power becomes more complete and extensive, involv- 
ing the upper extremities and muscles of respiration, and confining the 
patients to the recumbent position. The sphincters and other involun- 
tary muscles are not affected. During this final stage there is a rapid 
decrease in the size of the hypertrophied muscles, and the limbs may 
even come to present an appearance of great atrophy. 

There are no peculiar disturbances of the general health; the appetite 
and digestion remain good, and the mind clear until the close of the case. 
In Mr. Adams's case, however, the mental condition was peculiar, the boy 
being dull, heavy, indolent, and apathetic, with mischievous and dirty 
habits. Death usually occurs before adult age from some intercurrent 
affection of the respiratory organs. 

Duration. — As will be inferred from the foregoing description, the 
duration of cases of this disease varies from five to fifteen 3-ears, or more. 

Prognosis. — The course of this form of paralysis is steadily pro- 



590 PROGRESSIVE PARALYSIS. 

gressive, and, despite the various plans of treatment adopted, has uni- 
formly led to a fatal result. 

Diagnosis. — The only disease with which the affection under consid- 
eration could be confounded is progressive muscular atrophy; and even 
with this, error would be possible only during the early or late stages of 
the disease, before the appearance of the hypertrophy of the affected 
parts, or after this had disappeared. 

Progressive muscular atrophy is, however, very rare in childhood, and 
is characterized by the occurrence of atrophy preceding the paralysis, 
and by fibrillar contractions and quiverings in the affected muscles; 
while the peculiar symptoms present in progressive paralysis with appa- 
rent hypertrophy, are wanting. 

Morbid Anatomy. — The condition of the affected muscles has been 
studied, both during life, small fragments being removed by Duchenne's 
trochar (emporte-piece), and after death. 

Their color is altered, and the muscles present either a uniform pale 
or yellowish appearance, or are marked with stripes of yellow or yellowish- 
white ; on section the} 7 shiue with a dull, greasy lustre. 

Upon microscopic examination, the true muscular substance is found 
atrophied, the fibrils being pale and small, and in some places empty 
sheaths of sarcolemma are seen. According to Cohnheim (loc. cit.), the 
fibrils are occasionally reduced to one-fifth their normal diameter. Apart 
from this atrophy, however, the fibrils are healthy, and present neither 
fatty nor granular change. In this respect the cases recorded by Meryon 
differ from the others which have been examined, since he observed a 
granular degeneration of the muscular fibres, with rupture of the sarco- 
lemma (op. cit.). 

The most marked change is, however, in the condition of the inter- 
stitial tissue. This presents great hypertrophy of the connective tissue, 
with abundant formation of wavy fibrous tissue and of fat. It is proba- 
ble that, owing to this hypertrophy of the interstitial fatt^y-connective 
tissue, the muscular fibres are subjected to so much pressure as to induce 
simple atrophy. 

Xo lesions whatever have been detected in the central nervous system, 
in any of the few cases jet examined. 

Treatment. — So far as is 3-et known, no remedies appear to have any 
power to control the course of this strange affection. It is asserted by 
Benedikt (see Niemeyer, loc. cit.), that good results have been attained 
in three cases by the use of the direct current, the copper pole being 
placed over the lower cervical ganglion, and the zinc pole along the side 
of the lumbar vertebrae, b} 7 means of a broad metal plate. Xieme3 T er has, 
however, tried this mode of treatment for a long time without any success. 

Long-continued faradization and shampooing have also been found to 
produce no benefit. 



CLASS V. 

CONSTITUTIONAL DISEASES. 



AETICLE I. 

ACUTE RHEUMATISM. 

As it is not designed to enter into a full discussion of the numerous 
affections which merely occur in childhood in common with the other 
periods of life, we shall present hut a brief account of rheumatism in chil- 
dren, alluding particularly to those points in which it differs from the 
same disease in adults. 

The interest attaching to rheumatism among the diseases of childhood 
has been of late much increased by the connection which has been estab- 
lished between it and chorea. This question has been treated of under 
the head of the latter affection, and we will limit ourselves at this place 
to the discussion of acute articular rheumatism. 

Symptoms. — Acute rheumatism expresses itself in the child, as in the 
adult, by painful inflammation of one or more of the larger joints, usually 
accompanied by a high grade of febrile action. It is probable, however, 
that in the majority of cases in children, the fever is not so intense nor 
the course of the disease so long, as in adults. 

The fever, which is one of the most marked symptoms, may precede 
the development of inflammation of the joints by one or two da} T s, or 
raay coincide with the appearance of pain and swelling. It is generally 
marked in severe cases, and attended by frequency of the pulse, great 
heat of the skin, and, usually, copious acid perspirations. The heat of the 
skin and frequency of the pulse constitute a good index of the severity of 
the disease, and we may always apprehend a dangerous attack when the 
temperature rises above 104° or 105°. 

With this febrile action, we find disturbances of the digestive functions ; 
the tongue is heavily coated, the appetite lost, or nausea maj^be present, 
and the bowels are sluggish, the evacuations being dark and offensive. 

The local phenomena attending this fever depend upon acute inflam- 
mation of some of the large joints. 

Occasionally the ankles, knee-joints, wrists, elbows, and shoulder-joints 
will be simultaneously affected ; but in far the majority of cases, a few 
only of these articulations will be involved, and the others become affected 
subsequently, if indeed they do not escape entirely. But one of the most 
characteristic features of this specific rheumatic inflammation, though 



592 ACUTE RHEUMATISM. 

most marked in the chronic form, is its tendency to shift its seat, and we 
may find the intense pain and heat of one part transferred within twenty- 
four hours to a distant joint. We can rarely learn from the little patients 
the character of the pain which causes such bitter complaints: in one 
mild case, recorded by Rilliet and Barthez, it was compared to frequent 
light blows given upon the affected joints. 

The heat of the inflamed part is always much increased, and it is not 
unusual to find its temperature ranging from 100° to 105° (Aitken). 

The swelling is generally considerable, so that the shape of the parts 
may be much changed. When the knee-joint is inflamed, the effusion 
ma} 7 raise the patella from its position on the condyles. 

The skin over the inflamed joints usually presents a more or less de- 
cided blush. 

We must not, however, overlook the fact that the severity of these 
articular troubles is not always commensurate with the rheumatic fever, 
and that frequently, especially in very young children, the local signs 
may be slight or even absent, and the only feature which tends to reveal 
the real nature of the disorder ma,j be soreness, evinced by cries on every 
attempt to move the patient. 

Duration. — The duration of acute rheumatism varies exceedingly. 
According to Rilliet and Barthez, it follows a much more rapid course in 
children than in adults, occasionally yielding at the end of six days, and. 
nearly alwa} T s before the fifteenth day. We have, however, seen the 
rheumatic fever last twenty-one days, and before convalescence was fully 
entered upon, six weeks had elapsed. 

There is a marked tendenc} r to relapses and second attacks in rheu- 
matism, at whatever age it occurs; and we frequently meet with children 
of twelve or fifteen years of age who have passed through three or four 
acute attacks of this disease. 

Causes. — Age. — Early infancy appears to protect, to a certain extent, 
against this affection. Rilliet and Barthez allude to a case occurring at 
the age of seven months ; but the earliest age at which they met with it 
was at four years in a single case. 

We have ourselves observed one case in the second year, and several 
others between the close of the second and fifth years. 

The influence which sex exercises upon the frequenc}' of rheumatism 
in childhood seems still undetermined. It is usually stated that bo3~s are 
far more liable to the disease than girls, but in our own experience it has 
been more frequent in girls ; and from the register of the Children's Hos- 
pital in London (quoted by Tuckwell, St. Bartli. Eosp. Rep., vol. v, 1869, 
p. 102), it appears that of 418 cases of rheumatism treated during sixteen 
years, 252 were in females, and only 226 in males. 

Cold and Dampness. — Of external causes, the most prominent un- 
doubtedly are, sudden vicissitudes of temperature, especially when joined 
with dampness of the atmosphere, whereas the mere degree of coldness 
exercises but little influence upon its development. Of course the action 
of damp and cold is markedly increased by insufficient clothing. 

Complications. — We have already alluded to the occurrence of chorea 



PROGNOSIS — DIAGNOSIS — TREATMENT. 593 

and cerebral symptoms in connection with rheumatism (see article on 
chorea), and the most important and frequent of all these complications, 
the various inflammations of the membranes of the heart, have been 
treated of under the head of diseases of that organ. 

Prognosis. — Uncomplicated rheumatism in childhood, though at times 
severe, is scarcely ever fatal. When complicated, however, with endo- or 
pericarditis, the gravity of the prognosis must depend upon the extent 
and severity of the inflammation. For although, even when the heart is 
seriously involved, the child frequently survives the acute symptoms, it 
too often bears with it the seeds of premature death, in an organic disease 
of that organ. 

Diagnosis. — The diagnosis of acute rheumatism, after the appearance 
of the articular symptoms, can hardly present difficulty. When, however, 
marked rheumatic fever, accompanied merely by vague pains, precedes 
by several days the development of any local symptoms, the diagnosis 
must remain uncertain, or we may be led to regard as rheumatism one of 
those cases of phlegmon of the deep tissues of the extremities, such as is 
alluded to in the introductory essay of this work. In addition to this, 
we must be careful to distinguish the articular affections occurring in 
pyaemia, or those supervening upon attacks of small-pox and scarlet fever, 
which are probably also of pyaemic nature. The diagnosis in these cases 
must be chiefly established by attention to the general symptoms and the 
patient's history ; to the occurrence of repeated chills or irregular febrile 
parox3'sins, the diarrhoea, the greater degree of prostration and more 
rapid emaciation, and the more frequent fatality. The joints involved in 
these latter affections present large collections of creamy pus, and the 
articular cartilages are discolored, or eroded and destroyed in patches. 

Finally, Rilliet and Barthez cite a case (from Jour. Hebdomadaire, t. ii, 
p. 260) of hemorrhage under the periosteum of the clavicles, which simu- 
lated rheumatic inflammation of the sterno-clavicular joints, but which 
could be distinguished by ordinary attention to the general symptoms, in 
case of the occurrence of such a rare condition. 

From our own experience we should think that, during the early stage 
of rheumatic fever, the affections with which it might be most readily con- 
founded, are pleurisy and pneumonia, and typhoid fever. 

The absence of the plrysical signs of the two former affections, and of 
the diarrhoea and delirium of the latter, should we think lead the physi- 
cian to suspect the rheumatic nature of the attack. And if in addition 
there should be any fixed pain about the limbs, or unusual soreness and 
pain on being moved, or if any sign of cardiac inflammation be detected, 
this suspicion would be confirmed. Thus in a case seen by one of us, 
where at first the height of the fever and the great thirst led us to suspect 
the existence of pneumonia or pleurisy — of which, however, no plrysical 
signs could be detected — the occurrence, on the third clay, of complaints 
of pain in the right groin, led to a more careful examination of the heart, 
where the presence of a soft, faint mitral murmur, declared the nature of 
the attack. 

Treatment. — The indications for treatment presented by acute rheu- 

38 



594 ACUTE RHEUMATISM. 

inatism have been universally recognized as uniform, but the measures 
adopted to meet them embrace almost all known remedies. 
The prominent indications are : 

1. To aid in the elimination of the rheumatic poison, which has set up 
the specific inflammations and fever. 

2. To relieve pain. 

3. To guard assiduously against all complications, and to aid conva- 
lescence by suitable nourishment and tonics. 

Among the remedies which appear to be most productive of benefit, are 
alkalies, especially the bicarbonate of soda and acetate of potash, as 
recommended by Garrod ; the bromide of ammonium has also been used 
considerably of late, with apparent benefit. When the fever is very 
marked, nitrate of potash, in carefully graduated doses, is often bene- 
ficial. 

The iodide of potassium is most serviceable in cases of muscular rheu- 
matism, or in somewhat chronic cases of the articular form. Rilliet and 
Barthez assert that they have derived more benefit in the inflammatory 
complications of rheumatism (endo- and pericarditis, and pleurisy), from 
large doses of this salt than from any other drug. 

The remedies we have ourselves found most useful, consist of acetate 
and bicarbonate of potash with opium, which we are in the habit of giving 
during the acute stage, according to the following formula: 



R. — Potass. Acetat,, 
Potass. Bicarb , 
Tr. Opii, Deodor., 
vel Tr. Opii, Camph., 
Syr. Zingiberis, 
Aquae, 



• 33 • 

. gtt. xxiv. 

■ fgj. 

ad fgiij. 



Ft. sol. S. — A teaspoonful every two or three hours, at four or five years of age. 

Iron, particularly in the form of Basham's solution of the peracetate of 
iron, should be given so soon as the intensity of the fever has mitigated. 
The necessity for this remedy is but too often seen in the sallow, anaemic 
appearance of convalescents from rheumatism, which proves the rapid 
and extreme disintegration of the red corpuscles of the blood during an 
acute attack of this disease. 

When the acute symptoms have subsided, the alkalies may be dimin- 
ished and withdrawn, and quinia, in the dose of one grain every four 
hours, at the age of five j T ears, may be given in connection with opium. 

The following formula is one we frequently use for the administration 
of these remedies in this and other conditions : 



I£. — Quiniae Sulph., . 

Liq. Morph. Sulph., 
Acid. Sulph., Dil., . 
Curacoa, . 
Syrupi, 
Aquae, 



. gr. xxiv. 

. gtt. XXX. 

ad f^iij. 



Ft, sol. S. — A teaspoonful every four hours, at four or five years of age. 



TREATMENT. 595 

To fulfil the second indication, the mitigation of pain, opium must 
be given in proportion to the severity of the suffering. It is best given 
in small doses at short intervals, and by administering it in combina- 
tion with ipecacuanha, as in the form of Dover's powder, we derive the 
double benefit of a sedative and diaphoretic action. We have already 
given the formula by which we usually direct it in this disease. The in- 
flamed and painful joints should be bathed with a sedative liniment, as 
sweet oil, chloroform, and laudanum, and enveloped in bats of wool, and 
then covered with oiled silk, so accurately applied as to exclude entirely 
the external air. 

In addition to the other remedies, attention must be paid to the con- 
dition of the bowels, and if constipation exists, as is very frequent, mild 
saline laxatives or laxative enemata should be administered as frequently 
as required. Anything like purgation, however, should be avoided, on 
account of the excruciating suffering often produced by the movements 
necessaiy to have a stool. We desire, however, to call attention to the 
fact that young children with this disease may persist in lying in one 
fixed position for even several days, dreading to be touched ; so that 
there is added to the inevitable pain of the disease, the distress occasioned 
by the long-continued contact of single points of the opposing articulat- 
ing surfaces. Under these circumstances it is wise, and greatly promotes 
the comfort of the patient, to gently change the angle of the limbs by ar- 
ranging pillows so as to support them and alter their direction. 

In regard to the last indication — the prevention of complications — 
the most important means is the avoidance of all exposure of the patient 
to damp or to changes of temperature. In the fulfilment of this, the 
greatest care must be paid to the temperature of the sick-room, to the 
clothing of the patient, and to the mode of conducting all our examina- 
tions. Dr. Chambers, in his admirable lectures upon this subject (Clini- 
cal Lectures, American edition, pp. 156, ITT, &c), dwells with special 
force upon this point, and enjoins the exclusive use of blankets and flan- 
nels for the bedding and clothing of patients with rheumatism, and gives 
the following summary of his observations of the effects of this precaution 
alone in the treatment of nearly two hundred cases of rheumatism: " That 
bedding in blankets reduces from sixteen to four, or by three-fourths, 
the risk of inflammation of the heart, diminishes the intensity of the in- 
flammation when it does occur, and diminishes still further the danger of 
death by that or any other lesion." 

The importance of confinement to bed in this disease is difficult to 
over-estimate; the inflamed condition of the joints absolutely demands it, 
and the tendency to cardiac inflammation warns us to save the heart all 
unnecessary exertion, which strict attention, as above recommended, to 
the equable warmth of the surface, effects better than any other means. 

As to the diet in this affection, we must be guided by the acuteness of 
the symptoms and the condition of the patient. If the fever be marked, 
and the child vigorous, a diet chiefly consisting of milk and water is best 
suited to the early part of the attack, but so soon as the febrile stage has 
passed off, or when the patient is of feeble constitution, we may give soft- 



596 DIPHTHERIA. 

boiled eggs, and meat-broths, with advantage ; and frequently we will find 
concentrated nourishment and a moderate amount of stimulus required 
towards the close of the case. 

Complications. — In those cases where, despite our precautions, the 
membranes of the heart are threatened with inflammation, as evinced by 
sudden pain in the cardiac region, frequency of pulse, and oppression — 
even before the development of any murmurs — we should lose no time in 
applying local depletion by leeches or cups, abstracting as much blood as 
the urgency of the sjonptoms and the vigor of constitution justify. After 
the removal of the cups or leeches, warm mush-poultices should be ap- 
plied steadily over the whole precordial region. 



AKTICLE II. 

DIPHTHERIA. 

Definition : Synonymes : History : Frequency. — Diphtheria is an 
acute febrile, moderately contagious, and infectious asthenic blood dis- 
order, occurring also endemically and epidemically ; without character- 
istic eruption, and distinguished by a disposition to the formation of false 
membranes upon inflamed mucous surfaces, especially in the fauces, or 
upon abrasions of the cutaneous surface. 

It is the disease called by the older writers, angina maligna or gangre- 
nosa ; cynanche maligna ; garotillo ; angina suffocativa, under which name 
it was described by Dr. Samuel Bard, of Xew York, in one of the best of 
the early essays upon this subject {Trans. Amer. Philos. $oc, vol. i). 

It is, indeed, thought probable, that the history of this affection can be 
traced back to a period beyond the time of Hippocrates ; but unquestion- 
ably the writings of Aretseus, who flourished in the second century of the 
Christian era, contain a distinct description of this malignant sore throat. 
He describes it under the names of ulcus Syriacum and malum J3gyp- 
tiacum. 

From this period, there is quite frequent mention of the disease in the 
works of medical writers ; the earliest account of its appearance in modern 
times being given by Hecker, who describes an epidemic of it that pre- 
vailed in Holland, in 1337. 

About the middle of the last century, it prevailed in Paris, where it was 
described by MM. Malonin and Chomel; and in some parts of England, 
where it was studied and described b} r Fothergill, though it is now doubted 
whether the disease to which he refers was not more nearly allied to scar- 
latinous angina. 

The first full description of this affection published in this country, 
was the paper, alreacby referred to, by Dr. Bard, based upon an epidemic 
which appeared in 1771 ; the views advanced in which have been univer- 
sally recognized, even to the present day, as most clear and just. 

From that time, the complaint seems to have attracted but little atten- 
tion, until its occurrence at Tours, in 1818, and subsequent years, called 



FREQUENCY — CAUSES AND NATURE. 597 

forth the treatise of Bretormeau in 1826, in which he gave the first pre- 
cise notion of the disease, and bestowed the name diphtherite upon it. 

Since then it has occurred frequently epidemically in France; in 1857 
it appeared almost simultaneously in England, and in the extreme western 
part of onr own country, and from that time has occurred in the form of 
epidemics of greater or less extent and severity, in the most varied cli- 
mates and seasons, in almost all known parts of the globe. 

Diphtheria, the name by which this epidemic pseudo-membranous 
angina is commonly designated, is a synonjmie of the word diphtherite, 
originally used by Bretonneau in his treatise on this subject. 

AiwOspa and Aupdepuq both mean "the prepared skin of an animal;" and 
A'.cOtp'-r^ and AupOepiaq signifj- alike, "that which is covered with a skin 
or membrane." 

Xo cases of death from diphtheria in Philadelphia are reported in the 
annual lists of mortality published by the Board of Health, until the year 
1860. In the preceding report, however, Dr. Jewell mentions that several 
severe cases had occurred, some of which had proved fatal. One of us 
can, however, assert from his personal experience, that well-marked cases 
of diphtheria were of not rare occurrence in this city for a number of years 
before that time, but were reported under other names, and usually as 
either croup or angina. 

It is probable, however, that the disease did not prevail at all exten- 
sively previously to its great outbreak in 1860, as may be seen by a refer- 
ence to the number of deaths from croup and scarlatina, returned for the 
years preceding and subsequent to that date. 

TOTAL NUMBER OF DEATHS EROM 

1855, 

1856, 

1857, 

1858, 

1859, 

1860, 

1861, 

1862, 

1863, 

1864, 

The total number of deaths from scarlatina, from 1855 to 1859 inclu- 
sive, were 2332 ; from 1860 to 1864 inclusive, 1620, or U2 less than in the 
previous period. 

The total number of deaths from croup from 1855 to 1859 inclusive, 
were 1393 ; from 1860 to 1864 inclusive, 1815, or 422 more than in the 
previous 5 } T ears. And, further, during the latter 5 years, 1860 to 1864, 
the deaths from diphtheria amount to 1925. 

Causes. — In regard to the epidemic and occasionally endemic nature 
of diphtheria, the evidence is unanimously favorable, but it is still, to a 
certain extent, an open question as to how far it possesses contagious 
and infectious properties. 



Scarlatina. 


Croup. 


Diphther 


. 163 


265 




. 992 


268 




. 704 


256 




. 241 


292 




. 232 


312 




. 206 


354 


307 


. 329 


304 


502 


. 461 


258 


325 


. 275 


444 


434 


. 349 


455 


357 



598 DIPHTHERIA. 

Numerous authorities might be cited in favor of either of these to the 
exclusion of the other ; but the evidence adduced convinces ns that diph- 
theria is both contagious and infectious also, though to a moderate de- 
gree only. 

Bard, Trousseau, 1 Guersant, Yalleix 2 (who has himself fallen a victim 
to this disease), Billiet and Barthez, 3 Wood, 4 Empis, 5 and mauy others, 
attest to its contagiousness ; and we have ourselves seen unmistakable 
instances in our own practice. 

Bretonneau 6 also maintains strongly the infectious nature of diphtheria, 
and holds that it is transmitted directly by contact with the morbid pro- 
duct generated by the local disorder, i. e., the pseudo-membrane ; and it 
must be admitted that the cases now on record, in which the disease has 
been so transmitted, are too clear and well authenticated to permit of 
doubt. 

Apart from these well-ascertained properties, nothing is as jet known 
with regard to the general conditions which favor its production ; and it 
appears to have prevailed with equal severity in healthy and unhealthy 
situations ; in damp marshy districts and in dry hilly regions ; in the 
crowded filthy houses of great cities, and in sparsely populated villages ; 
in the depth of winter and in the intense heat of summer. 

Nov can it yet be positively asserted (although it is probably true with 
regard to diphtheria, as in the case of other zymotic diseases), that chil- 
dren of feeble constitution and those subjected to bad hygienic condi- 
tions, or debilitated by severe illness, are particularly exposed to it, es- 
pecially in the sporadic form. 

The effect of local causes, of a depressing character, upon the produc- 
tion of diphtheria was investigated by Dr. Ballard, 7 in regard to 57 fatal 
cases. Inquiries at the houses where the 57 deaths had occurred, showed 
that in 24 instances the houses were clamp, and that defective drains or 
some similar cause gave rise to offensive smells ; in 4 houses the inmates 
were overcrowded, and the ventilation deficient ; in 8 cases, the drinking- 
water was foul, or there was some noxious accumulation ; and in 25 cases, 
nothing whatever could be discovered amiss in the Irygienic condition of 
the houses. 

It is certain, however, that occasionally diphtheria appears in a spo- 
radic form, and isolated cases occur which can be attributed to no known 
cause whatever. 

We subjoin a table of the mortality from croup and diphtheria in this 
community during the past seven years ; upon which we base, to a great 
extent, the remarks which follow as to the causation of the latter disease. 

Season. — As we have already remarked, the influence of season upon 

1 Clin. Med., 2eme ed., 1865, t. i, p. 385. 

2 Guide du Med. Prat., 4eme ed., 1861, t. i, p. 530. 

3 Mai. des Enfants, 2eme ed., 1853, t. i, pp. 343-369. 

4 Pruct. of Medicine, 6th ed., 1866, vol. i, pp. 505-525. 

5 Memoirs on Diphtheria (New Syd. Soc. ed., 1859), p. 332. 

6 Id. Op., pp. 127 and 177. 

7 Med. Times and Gaz., July 23d, 1859. 



MORTALITY TABLE OF CROUP AND DIPHTHERIA. 



599 



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600 DIPHTHERIA. 

the prevalence of diphtheria is comparatively slight, and there are numer- 
ous records of epidemics occurring in the summer, as well as in the winter 
months. Notwithstanding, however, it will be seen that in our own city 
the mortalitj' from diphtheria does not vary very much during the months 
from September to March inclusive, whilst during the other five months 
it falls off from thirty to fifty per cent., the minimum mortality usually 
occurring in June. We have before had occasion to allude to the differ- 
ence, in this respect, between diphtheria and croup, which latter disease 
shows in the clearest and most marked manner the direct influence of 
season upon its frequency. 

Thus croup is far most frequent during the three months of November, 
December, and January, and, with the exception of February, becomes 
less and less frequent as you leave these months in either direction, 
until during July, the hottest month of our 3 r ear, it falls to even less 
than one-fourth of its maximum frequency. During the same month, 
diphtheria, whose maximum mortality is one-third less than that of croup 
(both maxima occurring in December), causes more than half as many 
more deaths than croup does, the proportion being 16.3 to 10. 

Sex appears to have absolutely no influence upon the frequency of 
diphtheria, since of 1804 fatal cases occurring in this city during the last 
seven years, 901 were males, and 903 females. 

Age, on the other hand, unquestionably exerts a very strong predis- 
posing influence, a large majority of all recorded cases occurring between 
the ages of one and eight years. 

Of the 1804 cases in our table, 190 occurred under the age of one year ; 
335 between one and two years; 125 between two and five years, and 355 
between five and ten years. Although the liability thus diminishes, in 
an uncertain ratio, with advancing years, no age is exempt from it. By 
reference to the influence of age upon the frequency of true primary croup, 
it will be seen that the maximum of its frequency is also attained between 
the ages of one and five years. We would also call attention to the much 
greater frequency with which diphtheria occurs in later life than croup ; 
since of 2136 deaths from croup, but 11 were over ten j-ears of age; while 
of 1804 deaths from diphtheria, not less than 199 occurred after that 
period. 

Nature. — In his earliest writings upon this subject, Bretonneau at- 
tached little importance to the constitutional s3 r mptoms attending diph- 
theria, and upheld the view that it was essentially a local affection; and 
though he subsequently somewhat modified his views, he yet only admits 
that the constitution becomes involved secondarily. 

It is indeed true that the epidemics which have occurred during the 
past twenty-five years seem to have been attended by far more grave con- 
stitutional symptoms than were present in the cases upon which Breton- 
neau's memoir was founded. And at present, it appears to us, that a 
careful study of the very numerous reports of epidemics occurring in all 
parts of Europe, Great Britain, and the United States, especially during 
the past ten years, can leave no doubt upon the mind that diphtheria is 



PATHOLOGICAL ANATOMY. 601 

a blood disease, attended with marked constitutional disturbance, which 
is usually of a decidedly asthenic character. 

This view is at present almost universally adopted ; and in accordance 
with it, we find diphtheria removed from the place which it formerly held 
in systematic treatises, among the local affections of the pharynx, and 
discussed as one of the general diseases. 

The chief arguments in favor of its being a constitutional disease, are 
its epidemic and contagious nature ; the continued febrile action, of as- 
thenic type, which attends its course ; the marked alteration of the blood 
mass in color and consistence ; the tendency to pseudo-membranous exu- 
dation on mucous membranes, or abrasions of the skin ; the occurrence of 
albuminuria; and, finally, the frequent development of paralytic sequelae, 
showing the presence of some morbid agent, acting especially upon the 
nervous system. 

Bouchut, 1 to a certain extent, agrees with Bretonneau. He divides 
diphtheria into false, or non-infecting, which is mere pseudo-membranous 
angina; and the true, or infecting, which involves the entire system, by 
means of the absorption of septic substances from the pharynx. In this 
respect it resembles pyaemia, and produces swelling of the lymphatics, al- 
teration of the blood, albuminuria, and even metastatic deposits. 

Pathological Anatomy. — False Membranes. — We have alread}^ dwelt 
upon the fact, that the pseudo-membranous exudation can no longer be 
regarded as the essential and most important element in diphtheria ; it is, 
however, one of the most constant and striking phenomena, and in cer- 
tain cases, where it extends into the laiynx, becomes the effective cause 
of death. 

It has been most carefully studied in regard to its mode of develop- 
ment and extension, seat, and microscopic characters, by Empis, Breton- 
neau, Wade, 2 Thompson, Darrach, 3 Trousseau, Sanderson. 4 

Mode of Development. — When fully developed, the pseudo-membranous 
deposit has the ordinary appearances of a fibro-plastic membrane ; but 
this stage is preceded, according to the researches of Empis and others, 
by the exudation of a sero-mucous, transparent, and viscid fluid ; which 
varies in abundance in different cases, at times even forming, as noticed 
by Trousseau and Empis, in the neighborhood of parts lately covered by 
deposit, a sort of submucous exudation, sufficient to raise the epithelium 
in the form of phlyctenae. 

This sero-mucous liquid does not long remain transparent and diffluent, 
but soon becomes a little less transparent in points, gains a j^ellowish 
tint, acquires greater density, and adheres more strongly to the subjacent 
mucous membrane. These points, at first isolated and circumscribed, 
soon coalesce so as to form a delicate pellicle, but slightly cohering, and 
capable of being raised from the mucous membrane by slight traction ; 

i Mai. des Enfants, 4eme ed., pp. 907-923. 

2 London Lancet, February 5, 1859 (et ante). 

3 Trans. Coll. of Phys. of Phila., February 6, 1861 (Amer. Jour. Med. Sei.). 
* Brit, and For. Med.-Chir. Rev., Jan., 1860. 



602 DIPHTHERIA. 

although, owing to its friability, it is difficult to raise a piece of any con- 
siderable size. 

This pellicle is more dense and thick at its centre than towards the 
edges, and soon after its formation, the exudation continuing beneath it, 
and coalescing with it, it gains in thickness by the apposition of an under 
layer; until, when the membrane is fully developed, it may consist of 
several la} T ers, and appear imbricated. 

At this period its adhesions are so strong that, if it be detached from 
its connections, slight hemorrhage will follow, or numerous minute bloody 
points may be seen upon the subjacent mucous membrane. 

According to Empis, the appearance of the opaque spots in the clear 
sero-mucous fluid is due to a precipitation of fibrin independently of any 
agency of living tissue. Thus the tubular casts which form in the air- 
passages are rarely adherent, and are usually much smaller than the 
cavity occupied ; and in cases of tracheotomy he has noticed the canula 
to become lined within a few hours with a layer of whitish concretion, the 
thickness of which continually increased, and which was evidently only 
the result of coagulation of the liquid by which the sides of the canula 
were constantly covered. 

Color. — The color of the pseudo-membrane varies at different stages, 
and somewhat according to its seat. 

In the fauces, the deposit is often whitish at first, but soon acquires a 
yellow tint ; though in some cases it is quite gray, and produces the ap- 
pearance of extensive sloughs on the fauces and pharynx. In severe cases, 
there is usually a bloody sanious fluid effused which imbues the pseudo- 
membrane, discolors it, and promotes its decomposition, so that it forms 
dark-colored shreddy patches, exhaling a fetid, gangrenous odor. 

It is essential to bear in mind that these appearances of the fauces in 
diphtheria are usually due to decomposition of the false membrane alone ; 
and that, if this be removed, the mucous membrane will generally be found 
merely raw, excoriated, and oozing blood. 

It is, however, true that in certain epidemics the rule has been for 
serious lesions of the mucous membrane, involving even its entire thick- 
ness, to occur. 

In milder cases, where the disappearance of the false membrane can 
be studied, it is never seen to separate all at once, leaving in its place a 
cicatrized surface, but the pellicle gradually diminishes in thickness and 
extent. When the pseudo-membrane extends into the larynx, it is more 
apt to remain whitish throughout its course there than in the fauces. 

Consistence. — The consistence of these deposits varies considerably. 
In cases of ordinary severit}^ where the s} T mptoms are not of a very 
adynamic type, the pseudo-membrane is often quite firm, tenacious, and 
elastic ; while in grave asthenic cases, with severe inflammation of the 
throat, the deposit is apt to be much less firm, or even quite pultaceous. 

It has been attempted to base upon these conditions and the corre- 
sponding microscopic appearances, a division of diphtheritic pseudo- 
membranes into two classes, answering to the well-known division of in- 
flammatory lymph into the fibrinous and the corpuscular. 



MICROSCOPIC ANATOMY AND CHEMICAL CHARACTERS. 603 

Microscopic Anatomy. — There were formerly different views enter- 
tained with regard to the minnte anatomy of the pseudo-ineinbraiious 
deposits in diphtheria. 

Togel originally associated with the disease the presence of the oidinm 
albicans, the parasite which we have seen to be characteristic of mnguet ; 
and. more recently, Laycock, of Edinburgh, has insisted upon the occur- 
rence of this cryptogam in the pseudo-membranes of diphtheria. 

Dr. Wade, of Birmingham, has noticed also in some cases, in or near 
the exudation, the spores of the leptothrix buccalis, a fungus very com- 
monly met with in the secretions of the moutt and pharynx. 

Further investigations have shown, however, that these parasites are 
occasionally present in numerous diseased conditions of the mouth and 
fauces, and that their occurrence in diphtheria is to be considered as a 
mere accident, and not as an essential part of the affection. 

The microscopic appearances which are constant, are the ordinary 
elements of corpuscular lymph : exudation cells or even pus corpuscles, 
granule cells and free fatt}^ granules, and more or less abundant and 
closely interlacing fibrillar, mixed with epithelial cells of various shapes 
and sizes. In the majority of specimens, the corpuscular elements greatly 
predominate, the fibres being few and small ; and indeed it is only in the 
firmer, more tenacious, pseudo-membranes that much true fibrillation is 
noticed. 

Chemical Characters. — The false membranes contract and shrivel when 
treated with alcohol ; mineral acids, such as sulphuric, muriatic, nitric, 
or chromic ; strong solutions of nitrate of silver ; or solutions of the per- 
salts of iron. 

On the other hand, they soften more or less quickly when treated with 
alkaline solutions, as of potassa, soda, lime, or ammonia ; or of chlorate 
of potash, chlorate of soda, bromide of potassium; or with glycerine and 
various other agents. Recently, pepsin has also been announced as a 
powerful solvent. These various chemical properties are constantly 
turned to account in the treatment of diphtheria, in guiding our selection 
of the most appropriate local applications. 

Condition of subjacent Mucous Membrane Even before the appear- 
ance of the slightest exudation, the mucous membrane of the fauces is 
often seen to be red and somewhat swollen. After the pseudo-membrane 
is fully developed, it is of course impossible, without forcibly detaching it, 
to gain any idea of the condition of the mucous membrane beneath, and 
unquestionably very many of the descriptions given of extensive gan- 
grenous ulceration of the fauces and pharynx, have referred merely to 
the changes in the pseudo-membrane due to its decomposition and the 
imbibition of sanious fluid. 

In the vast majority of cases, the subjacent mucous membrane is not 
truly ulcerated, but is merely much congested and swollen, with an ex- 
coriated and roughened appearance from removal of its epithelium, and 
occasionally presents spots of ecchymosis. 

At times it is whitish, opaque, or unnaturally pale; while in other cases 
it is purplish or otherwise discolored. When the deposit is raised up, 



604 DIPHTHERIA. 

especially if it be of the firmer variety, it is often seen to be attached to 
the surface beneath b} r numerous small filaments, as though processes of 
the deposit passed into the mucous follicles. 

Although these may be considered as the most usual conditions of the 
mucous membrane, it is undoubtedly true that in some cases extensive 
and deep ulceration, and even gangrene occur, exposing the muscular 
tissue of the pharynx, or even producing the destruction by sloughing 
of an entire tonsil gland. 

This accident occurs much more frequently in some epidemics than 
others, as may be readily s^een by a comparison of the accounts given by 
different authors of the anatomical lesions noticed in the epidemics they 
have respectively studied. 

The submucous tissue is often oedematous, infiltrated with bloody se- 
rum, or is the seat of an interstitial exudation of lymph. In some cases 
the oesophagus and the muscular tissue around the fauces and pharynx 
are congested and infiltrated. 

When croup ensues, the mucous membrane of the larynx and trachea 
is more or less swollen and congested, and, according to West, presents 
distinct erosion of its surface, with small ulcers about the edges of the 
glottis, in a larger proportion of cases than ulceration is met with in the 
fauces. M. Isambert 1 suggested that this condition might serve to dis- 
tinguish diphtheritic from idiopathic croup ; but West has met with pre- 
cisely similar ulceration of the mucous membrane of the larynx in cases 
of primary croup, and is disposed to regard its presence or absence as 
mainly dependent on the rate of progress of the disease towards a fatal 
termination. 2 

Seat of the Exudation. — The pseudo-membranous deposit is usually 
first seen upon the tonsils and soft palate, and in some cases is limited to 
these parts throughout the whole course of the case. 

Frequentty, however, the exudation spreads and coats the pharynx 
more or less extensively, or extends into the posterior nares, or down- 
wards through the larynx into the trachea and bronchi, or more rarely 
into the oesophagus. 

It is rare for any exudation to occur on the mucous membrane lining 
the cheeks, or upon the gums, though according to some authors, as 
Hutchinson 3 and Bouchut, ulcerative stomatitis is in reality buccal diph- 
theria. The epiglottis is at times covered with a pseudo-membranous 
deposit, so as to become swollen, rigid, and almost immovable, and hence 
partially obstructing, without being able to protect, the entrance into the 
larynx. 

The tendenc}^ for the exudation to extend into the nasal passages 
varies much in different epidemics, and when present, almost alwa}'S be- 
tokens the great gravity of the case. 

According to Bretonneau, the exudation occasionally begins in the 

1 Arch. Gen. de Med., March and April, 1857. 

2 Diseases of Children, 4th Am. ed., 1866, p. 356. 

3 Med. Times and Gaz., March 19, 1859. 



SEAT OF THE EXUDATION. 605 

nares and extends thence in so insidious a manner as readily to escape 
detection. 

We will discuss more fully the questions relating to the extension of 
the exudation into the larynx under the head of diphtheritic croup. 

The diphtheritic pseudo-membrane is not, however, limited to these 
mucous surfaces, but is occasionally seen, and especially in very severe 
cases, to form upon the mucous membrane of the vulva or of the anus. 

It is, moreover, a most significant fact in regard to this affection, that 
any portion of the external cutaneous surface which has been denuded of 
epidermis, may become the seat of this deposit, and that in some cases 
the pseudo-membranous formation is even limited to the skin, constitut- 
ing the so-called external or cutaneous diphtheria. So far, however, from 
the attending constitutional symptoms being less severe in the external 
than in the ordinary form, the tendency to deposit upon the cutaneous 
surface usually presents itself in cases of a typhoid adynamic type. 

It appears, indeed, that this pseudo-membrane may occur at any point 
of the bod} T to which the atmospheric air has access ; but it has never 
been noticed on parts which are removed from its influence. 

Xotwithstanding these apparently distinctive features of the diphther- 
itic deposit, it is impossible b}^ mere ocular or microscopic examination 
to distinguish it from the pseudo-membranous deposit in cases of ordi- 
nary scarlatinous angina. 

It is more, therefore, in the peculiar constitutional disturbance that 
we must look for the specific nature of diphtheria than in the presence and 
characters of the false membranes. 

Tlie Submaxillary Glands are almost always enlarged, though they 
rarely acquire the enormous size and peculiar brawny induration so often 
noticed in scarlatina. It is, moreover, very rare for this condition to 
terminate in suppuration of the gland. 

The Heart has been found, by Hillier, 1 in a state of fatty degeneration 
in two cases, and by Bristowe (id. loc.) in one ; all of which were rather 
chronic. In some instances where symptoms of endocarditis were present 
during life, the auriculo-ventricular valves have been found in an incipi- 
ent stage of inflammation. (Bridger. 2 ) 

Heart-clots of large size and firm consistence, evidently of ante-mortem 
formation, are also found in a certain number of cases where death has 
been preceded by peculiar signs of circulatory embarrassment. 

The Lungs are not rarely found inflamed and consolidated to a greater 
or less extent. In other cases the exudation is found penetrating deeply 
into their structure, filling the smaller bronchial tubes, and the lung itself 
is in parts collapsed or carnified. 

Bouchut speaks of having seen small apoplectiform patches, similar to 
those which precede the so-called metastatic abscesses in pyaemia. 

The Kidneys are at times quite healthy ; in other cases, however, they 
have been found congested, and the renal epithelium granular and de- 

i Diseases of Children, Am. ed., 1868, p. 154. 

2 Med. Times and Gaz., Jan., 1864, p. 201 ; and Brit. Med. Jour., Oct, 22, 1864. 



606 DIPHTHERIA. 

tacked, so as to distend the tubules, which also contain fibrinous casts 
(inclosing granules of hsematin, blood-corpuscles, or a few altered epi- 
thelial cells). (Hillier (Joe. czY.), Greenhow, 1 &c.) 

The g astro-intestinal canal presents no lesions of importance ; in a few 
cases enlargement of the solitary glands of the lower part of the ileum 
has been noted. 

Secondary Form. — When diphtheria appears in the secondaiy form, 
the mucous membrane is more violently inflamed. It is of a deep red 
color, rough, and very much thickened and softened. The tonsils are 
large and soft, uneven, and often infiltrated with pus. In addition, the 
mucous membrane is far more frequently and seriously ulcerated in this 
form than in the primary. False membranes are almost always present, 
generally on different portions of the fauces, and more rarely over their 
whole extent. They are generally rather soft and thin, of a whitish, 
grayish, or j^ellow color, dispersed in fragments and easily torn. 

The inflamed parts are usually bathed in a purulent fluid. The sub- 
maxillaiy glands are large, red, and soft; and, in addition, there m&y be 
found various lesions of other organs, due to the primary disease, in the 
course of which the diphtheritic angina has been developed. 

Symptoms. — Diphtheria presents itself either as a primary or secondary 
affection. The symptoms of this latter form are, however, so involved 
with the s3 T mptoms of the diseases in the course of which it is developed, 
that it seems desirable to consider it in connection with them severally. 

The s} T mptoms of primary diphtheria demand much more attention at 
the present day than was accorded to them a few years ago. 

So long as the disease appeared but rarely, and in a sporadic form, it 
seems- to have been attended with few grave symptoms, save when exten- 
sion of the pseudo-membrane to the larynx gave rise to croup ; but since 
the prevalence of diphtheria in epidemic and endemic forms, the type of 
the disease appears to have changed, and though cases still occur with 
but trifling constitutional disturbance, there are others, and not less nu- 
merous, which present all the gravest symptoms of blood-poisoning. 

In a strictly systematic discussion it might be well to divide diphtheria 
into a mild form, which would include most sporadic cases and many of 
the epidemic ones, and a severe form, under which head would be com- 
prised all cases distinguished by a high degree of constitutional disturb- 
ance. For practical purposes, however, it is sufficient to give a descrip- 
tion of the ordinary course of the disease, dwelling upon some of the 
most important s} r mptoms, and alluding to the chief peculiarities which 
at times present themselves. 

Local Symptoms. — Examination of the Throat. — The onset of diph- 
theria is often very insidious ; so that our attention may not be called to 
the throat by any complaint of the patient, even when a considerable 
amount of exudation is already present. 

If the throat be examined, however, on the first day of the disease, the 
exudation may often be found even at that time, though it is sometimes 

i On Diphtheria, New York, 1861, p. 160. 



LOCAL SYMPTOMS. 607 

not found before the second day. The fauces generally present slight 
swelling and redness prior to the appearance of the false membrane, 
which almost always shows itself first on one of the tonsils, only, in the 
form of whitish or opaline spots, like coagulated mucus, which soon run 
together and extend over the whole gland, and then to the soft palate 
and pharynx, though it sometimes remains limited to the tonsils and soft 
palate. A little later in the attack the plastic deposit exists in the form 
of layers of greater or less extent ; it has lost its transparency, become 
firmer in consistence, thicker, and changes from a white to a yellowish- 
white or lardaceous, and sometimes grajnsh color. 

The breath in this case is offensive, but not fetid ; and there is but 
little salivation. 

When in favorable cases, this disease is left to pursue its natural course, 
the pseudo-membrane becomes thinner, assumes a grayish tint, and falls 
off about the sixth or seventh day. When, on the contrary, topical reme- 
dies are applied to the throat, the membrane is often detached after one, 
two, or three days, but may be reproduced several times before the con- 
clusion of the case. 

In some unfavorable cases, on the contrary, even though the exudation 
ma} T disappear more or less completely from the pharynx, it extends down- 
wards into the larynx, and we have true croup developed, which, but too 
often, proves fatal in spite of all remedies. 

In more violent cases, the pseudo-membrane, about the time that it be- 
gins to be detached, assumes a grayish or blackish color, and hangs in 
shreds from the surfaces to which it was attached. The fauces, under 
these circumstances, present a gangrenous aspect, the mucous membrane 
having an appearance as though it were falling off in sloughs ; the breath 
is extremely fetid, and there is more or less abundant salivation, or in 
some cases an expuition of sanguinolent fluid. 

There can be no doubt that it was from misconception of such cases as 
these, that the titles of gangrenous and putrid sore throat arose. 

As the exudation disappears from the pharynx, the swelling of the 
parts affected gradually subsides. The mucous membrane, from which 
the plastic matter has just fallen, is more or less injected and red ; the 
tonsils and soft palate are sometimes found to be reduced below their 
natural size. 

Even when the throat affection is very severe there is not often so 
much difficulty in opening the jaws nor in deglutition as is met with in 
scarlatina. 

The submaxillary glands are almost always enlarged and slightly 
painful to the touch, about three or four days after the appearance of the 
pseudo-membrane. The enlargement is usually greatest on the side where 
the inflammation of the fauces is most intense. The surrounding cellular 
tissue shares in the inflammation, so that the swelling is often very great, 
and impedes the movements of the jaw; it is rarely, however, save in 
very bad cases, so hard and painful as the corresponding swelling in 
scarlatina. 

Pain and Difficulty in Deglutition.— -There is quite frequently no com- 



60S DIPHTHERIA. 

plaint of pain in the throat, although, even at the outset, swallowing is 
usually somewhat difficult and painful, and pressure behind the angles of 
the jaw causes a moderate degree of suffering. 

As the pseudo-membranous exudation increases, and the submaxillary 
glands become swollen and tender, deglutition becomes more difficult 
and painful, and, at times, attempts to swallow fluids are followed by 
cough and the return of the fluid through the nostrils. 

In cases where the false membranes decompose and acquire a gangren- 
ous aspect, and typhoid symptoms are present, the pain and difficulty 
in swallowing, if the}^ have existed, are apt to disappear. 

Varieties Depending upon. Extension of the Exudation. — 1. 
Groupal Variety. — It would be a matter of much interest to determine 
in what proportion of cases this complication may be anticipated, and 
whether there be any definite and constant relation between the amount 
or character of the exudation in the pharynx and its extension to the 
larynx. As yet, however, no general conclusions can be arrived at in 
regard to any of these points. The frequency of its occurrence varies 
much in different epidemics, the proportion varying from one or two per 
cent, to as high as fifty per cent, of all the cases. 

As might be expected from the considerations presented under the 
head of croup, this complication occurs more frequently and is much more 
fatal in children than in adults. 

It is a well-recognized fact that true diphtheritic croup is nearly always 
preceded or accompanied by pseudo-membranous exudation in the fauces 
or pharynx, but the amount of deposit in these latter places may be ex- 
tremely small and } r et be followed by extensive exudation in the air-pas- 
sages ; while, on the other hand, there is often copious deposit upon the 
phaiynx in cases where the laiynx does not become invaded. 

Xo case, indeed, is free from the chance of this complication; it consti- 
tutes the chief source of danger in the mild variety, and yet is occasionally 
met with as the immediate cause of death in the most malignant attacks. 

The pseudo-membrane is quite frequently found, in cases where the air- 
passages have become involved, to extend through the larynx and trachea, 
as far down as the tertiary bronchi, or in some instances, even to their 
finest divisions. 

In this respect diphtheritic croup does not differ from primary croup, 
unless it be, indeed, that it seems to be more frequent in the former for the 
exudation to extend to the smaller bronchial tubes. 

We have seen that there is no essential difference in the condition of 
the mucous membrane beneath the deposit in the two affections ; and that 
they are equally liable to be associated with inflammatory conditions of 
the lungs. 

Unless, therefore, the more highly corpuscular character of the exuda- 
tion in diphtheria constitutes a ground of distinction between these two 
forms of croup, it seems difficult to establish a diagnosis between them 
on merely anatomical grounds. 

When diphtheritic croup is secondary, appearing in the course of 
measles, scarlatina, or other general disorders, the conditions found after 



SYMPTOMS OF DIPHTHERITIC CROUP. 609 

death in the larynx are much the same as in primary diphtheritic croup. 
The mucous membrane here, however, as in the fauces, is usually more 
intensely inflamed, and is more frequently ulcerated. 

The possibility of the occurrence of croup should never be lost sight 
of, and every case should be treated as though it tended to invade the 
larynx. It is especially important to detect the very earliest signs of the 
approaching danger, since its onset is frequently extremely insidious. 

If violent cough is excited by attempts to swallow liquids, it usually 
indicates that the epiglottis is inflamed, and the seat of pseudo-membran- 
ous exudation, which impedes its movements and thus allows the fluid to 
pass into the larynx. The extension of the exudation to the larynx is 
indicated b}~ the cough acquiring a rough croupy sound, though it often 
has not the loud clangor of ordinary croup; the respiration becoming 
sibilant, and the voice weak and hoarse. 

"When the false membrane in the larynx is fully developed, the voice is 
almost or quite extinct, and the cough, losing its croupjr character, be- 
comes stifled and less frequent. The respiration is now peculiar ; there 
is constantly a certain degree of dyspnoea, as shown by the frequent 
labored breathing, but there are, in addition, paroxysms of suffocation, 
induced b}^ spasm of the laryngeal muscles, during which the dj^spncea 
is frightful, and attended with tossing of the whole body and the most 
violent efforts at inspiration. 

Death may occur during one of these paroxysms ; but usually they sub- 
side and are followed hy intervals of comparative ease, soon interrupted 
by the recurrence of the same alarming phenomena. 

The intervals become more and more brief, and finally the patient sinks 
into a comatose condition, and dies with all the symptoms of asphj^xia. 
If, during the violent efforts at respiration which attend these paroxysms 
of dj'spncea, or owing to the action of remedies, portions of the exuda- 
tion are dislodged and coughed up, the most urgent symptoms are often 
immediately relieved. It is, however, but a deceitful repose, for in most 
cases the pseudo-membrane reforms, and the recurrence of the croupy 
voice and sibilant respiration announce that the danger of suffocation is 
again imminent. 

In favorable cases, however, either when the membrane does not re- 
form, or when it is dislodged as often as formed, recovery may occur; 
the paroxysms of dyspnoea recur at lengthening intervals, and finally dis- 
appear ; the cough becomes gradually more soft, and fragments of pseudo- 
membrane, mixed with muco-purulent fluid, are discharged ; the voice re- 
turns, and the capillaiy circulation becomes re-established. 

In some cases, when the exudation has extended through the larynx 
and trachea deeply into the minute bronchial tubes, there is an absence 
of marked croupal symptoms, and death occurs slowly, after extreme 
dyspnoea and oppression of the chest, with all the symptoms of deficient 
aeration of the blood. These cases occur more frequently in adults than 
in children on account of the larger size of the larynx in the former. 

The reader is referred for a more full account of this condition to the 
article on pseudo-membranous laryngitis. 

39 



610 DIPHTHEEIA. 

2. Nasal Variety. — We have already mentioned that Bretonneau states 
that the disease occasionally begins at the nares, and extends thence in 
a most insidious manner. More frequently, however, the affection of the 
nares is consequent upon a extension of the exudation from the pharynx. 

This complication is second in gravity only to the occurrence of croup. 
It impedes still further the already obstructed respiration, is attended 
with a foul acrid discharge from the nostrils, and, in addition, experience 
has shown that it is usually a sign of great malignancy in the case. Ac- 
cording to Trousseau, the result is almost alwa} T s fatal, the blood-poison- 
ing being marked, as shown by the great alteration in the physical prop- 
erties of the blood, the proneness to hemorrhages, the wax}^ pallor of the 
skin, and the ultimate fatal termination by s} T ncope. 

The detection of this complication in its incipient stage is therefore of 
the highest importance, and Bretonneau (5th memoir, Syd. Soc. Trans., p. 
196, 197) has laid down the most minute directions for its recognition 
at this stage. If the patient present an}^ evidence of disease of these 
passages, as a slight snuffling or coryza, during the prevalence of diph- 
theria, the finger should be placed behind the angle of the lower jaw, 
below the lobe of the ear, and thence passed down the side of the neck, 
and if swelling of the cervical glands be noticed, it renders it probable 
that there is false membrane in the nares. 

If, further, the upper lip be found reddened exclusively under one 
nostril, and that on the side of the glandular swelling, or if the swelling 
exists on both sides, but unequally, and if the lip is correspondingly 
reddened, the probability that there is nasal diphtheria is converted into 
a certainty, since ordinary coiyza, acting equally on both nostrils, pro- 
duces equal redness of both sides of the upper lip. 

3. Cutaneous Diphtheria. — It is one of the characters of diphtheria 
which entitles it to be regarded as a blood disease, that different and dis- 
tant parts are apt to become affected simultaneously or consecutively with 
the peculiar inflammation and exudation. We find, indeed, that in many 
cases of diphtheria there is a tendency to the formation of pseudo-mem- 
brane upon any portion of skin denuded of its epidermis. 

This tendency varies greatly in different epidemics ; according to our 
experience it is of rare occurrence in this city. It was, however, noticed 
by Bard nearly a century ago, and has been made the subject of special 
stud} T hy Bretonneau and Trousseau. 1 The pseudo-membrane forms upon 
an}' blistered surface ; upon leech-bites ; upon excoriations ; in fissures, as 
behind the ears, or at the angles of the mouth ; or on the outlets of the 
vagina and rectum. 

The part that is to be the seat of pseudo-membranous deposit becomes 
surrounded by an erysipelatous redness ; it is painful, exudes an abun- 
dant fetid serous fluid, and soon becomes covered with a grayish false 
membrane. This deposit gains in thickness from beneath ; and at the 
same time extends in every direction, by the development of vesicles 
in the neighborhood, the bases of which become the seat of diphtheritic 
deposit. 

■ ■*» 

1 On Cutaneous Diphtheria, Arch. Gen. de Med., 1830 (et loc. ante eit.) 



GENERAL SYMPTOMS. 611 

The layers of membrane, bathed in the fetid serous fluid, soon change 
color, decompose, become horribly offensive, and impart the appearance 
of true gangrene. 

Trousseau has observed this cutaneous exudation in cases where no 
affection of the throat existed, and has clearly established the identity of 
these various forms of diphtheria by facts collected in an epidemic in the 
neighborhood of Orleans, where the disease in some persons presented its 
ordinary features, while in others the exudation occurred on the vulva, on 
blistered surfaces, on the hairy scalp affected with favus, or upon ulcers. 

The constitutional symptoms which accompany cutaneous diphtheria 
are usually extremely grave and adynamic. 

General Symptoms. — In the mild form of this disease, the invasion 
is often highly insidious ; there is usually fever, but the strength and 
appetite are not much disturbed at first. There is at the same time, in 
some, but not all cases, pain in the throat, which may or may not be ac- 
companied by difficulty of deglutition. Both these symptoms are, how- 
ever, often very slight, or they may be entirely wanting, a fact with which 
the practitioner should be well acquainted, as this absence of local symp- 
toms b} T which to explain the cause of the sickness, gives to the disease, 
in some instances, a remarkably insidious character which may well mis- 
lead. In one fatal case, at three 3 7 ears of age, that came under our notice, 
there were neither complaints of pain, nor difficulty of swallowing, so 
that the parents had not the least suspicion of the throat being the 
seat of disease, though we found it violently inflamed, and covered with 
deposits of thick false membrane in points. On another occasion, we 
were sent for to see two children who had been sick for four days with 
slight fever, languor, and loss of appetite, but who were not thought to 
be seriously ill. We found them laboring under extensive pseudo-mem- 
branous angina, with the early symptoms of croup. They both died a 
few days later of croup. The symptoms, prior to the development of the 
croup, had been so mild in both cases as to cause no alarm, and yet the 
anginose disease had evidently been progressing insidiously for several 
da\*s. We attended a few years since, for three days in succession,, a 
boy who was attacked suddenly with vomiting and slight fever, loss of 
appetite and languor, and whom we supposed to be suffering from mere 
gastric irritation. His only local symptom was pain in the chin, and this 
was not reported to us until afterwards. The mother chanced to look 
into his throat, and, finding there some whitish spots, sent us word.. We 
found him with very considerable membranous exudation, which was for- 
tunately prevented from extending into the larynx by proper treatment. 
Quite frequently have we been sent for to see children attacked with 
croup, and on finding the fauces thickly covered with exudation, have been 
told that the patient has been ailing for near a week before with languor, 
slight peevishness, loss of appetite, and some little pain in the throat. To 
this point, the strangely insidious character of the anginose symptoms in 
the early stage of many cases, we cannot too strongly invite the attention 
of the reader. It is one of the very greatest importance, since at that 
time, above all others, ought the case to be placed under proper treatment. 



612 DIPHTHERIA. 

The constitutional symptoms are indeed so trifling in some of these 
cases, that the name diphtheroid sore throat has been applied to them. 

It has been on the other hand stated, that, during epidemics of diph- 
theria, cases occur which present the usual general symptoms, with some 
difficulty of swallowing and swelling of the cervical glands, but in which 
no pseudo-membrane is formed, the fauces being merely of a dark red 
color, with swelling and elongation of the uvula, and sometimes tumefac- 
tion of the tonsils. 

Such cases are rarely fatal, and, as a rule, 3 T ield readily to the ordinary 
treatment for diphtheria. 

These mild cases, in which the only danger is from the extension of 
the exudation into the larynx, are, however, far from constituting diph- 
theria as it is now known to us ; and there are numerous cases in which 
the gravity depends not upon an accidental extension of inflammation, 
but upon the essential alteration of the blood, and the condition of the 
entire s} T stem. 

In these cases also the onset may be insidious, though it is often 
preceded for a short time by general malaise, indisposition to play on 
the part of children, and to exertion on that of adults, and slight swell- 
ing of the cervical glands, and pain on deglutition. 

Whether these prodromes have been present or not, a more or less 
marked chill ushers in the febrile action, which is often quite intense for 
a few days ; so that, when the throat affection is decided, a doubt may 
exist for a short time, whether the approaching attack is one of scarlatina 
or diphtheria. The fever, however, soon subsides almost completely, 
sometimes indeed leaving the surface pale and cooler than natural. The 
pulse may remain frequent, but is weak and compressible ; and the gen- 
eral symptoms are all characteristic of deficient vital force. 

There is not usually any marked mental disturbance after the second 
day, the child being intelligent, though dull and indisposed to pay atten- 
tion to anything. 

There are but few symptoms of digestive disorder ; the appetite, which 
is often retained for the first day or two, soon diminishes, and the child 
often becomes unwilling to take any food, partly from the pain caused 
by the efforts to swallow, partly from complete anorexia. There is rarely 
any vomiting, unless provoked by remedies; and the bowels, though 
usually torpid, occasionally incline to be loose. The urine is rather 
scanty, quite frequently albuminous, and upon microscopic examination 
is found to contain renal epithelium, and casts from the renal tubules. 
This symptom will be again and more fully alluded to among the compli- 
cations. 

At the same time, the submaxillary glands enlarge, and the fauces 
assume the appearances we have already described. There is a great 
increase in the secretion of saliva, which often dribbles quite profusely 
from the mouth, and is apt to be offensive, though rarely fetid. In many 
cases there is in addition a discharge from the nostril, which becomes 
acrid and offensive when there are false membranes in the nasal passages. 



GENERAL SYMPTOMS. 613 

The voice is commonly obscured and nasal, or somewhat hoarse, even 
when the larynx is not involved. 

Cough sometimes exists, and may have a slightly ringing spasmodic 
character, due to mere irritation of the larynx, though it usually resembles 
in sound that produced by the action of hawking, rather than a common 
cough. 

In a very small proportion of the cases, an eruption, resembling that 
of scarlatina, appears at irregular periods in the course of the disease. It 
appears, however, that this eruption lacks the punctated appearance of 
the scarlatinous rash; does not appear at any fixed day of the disease ; is 
irregular in its progress, and is not followed by desquamation. 

The reports of it are, however, scarcely numerous or accurate enough 
to enable us to sa} T positively that intermingled cases of scarlatina have 
not been mistaken for diphtheria, or that the two poisons may not have 
been acting jointly. 

The further course of these cases varies widely. If the result is to be 
unfavorable, the depression and loss of strength increase rapidly; the sur 
face grows pale or sallow, and is below the natural temperature ; the pulse 
becomes exceedingly frequent and feeble ; the fauces assume a gangre- 
nous appearance from decomposition of the false membranes ; the swelling 
of the cervical glands increases, and the patient often refuses to make the 
effort to swallow, though deglutition is still generally possible ; there is a 
constant fetid discharge from the mouth and nostrils ; the breath is horri- 
bly offensive ; and death ensues amid the most profound prostration. Or, 
at a much earlier period of the disease, the fatal event may be precipi- 
tated by the extension of the exudation to the larynx. 

If, on the other hand, the case tends towards recovery, the false mem- 
branes become detached and thrown off, the strength improves, the pulse 
becomes fuller and stronger, and the appetite returns. Even in advanced 
convalescence, however, there is serious danger, as will be seen more 
fully hereafter, of the occurrence of troublesome or even fatal sequelae. 

In a still more severe group of cases than those above sketched, the 
symptoms are of the most asthenic or malignant type. 

In these cases the anginose affection, though it ma}^ be severe, rarely 
attracts much attention. The pseudo-membranes in the fauces are soft 
and pulpy, and, when examined microscopically, highly corpuscular and 
granular; they soon decompose, and become discolored by the blood 
which exudes from the mucous membrane. There is, moreover, a strong 
disposition for the exudation to extend to the posterior nares, or to appear 
on various portions of the external cutaneous surface. The breath and 
the discharge from the mouth and nostrils are indescribably fetid. In 
some cases true ulceration, and even gangrene, of the fauces occurs. 
There is, however, less pain complained of, and less indisposition to 
swallow than in many lighter cases, owing probably to the depression of 
the nervous centres from the poisoned state of the blood. There may be 
high fever during the first few days, but this soon disappears, and is re- 
placed by a deadly pallor of surface ; extremely feeble, running pulse ; 
and at times low muttering delirium. 



614 DIPHTHERIA. 

Passive hemorrhages from the nostrils, mouth, rectum, or other mucous 
passages, are of frequent occurrence. 

The result in these cases of profound diphtheritic infection is almost 
invariably fatal ; death resulting quietly from pure exhaustion, without 
the development of any complications. 

The duration of diphtheria varies considerably. Ordinary cases re- 
cover in about seven, eight, or nine days, whilst more severe attacks are 
often protracted until the end of the second week. 

It is impossible, however, to sa} T that the disease has actually run its 
course in this time, since there are sequelae which may appear during ad- 
vanced convalescence, and retard the recovery even for many weeks. 

On the other hand, in fatal cases, death may occur from croup as early 
as the end of the second day; though usually the laiynx does not become 
implicated under five or six clays, and this accident may occur so late as 
the twelfth or fourteenth day of the attack. 

In extremely malignant cases, death may also occur during the first 
few days. On the whole, however, it may be said that the majority of 
deaths from all causes occur in the period between the sixth and twelfth 
da} T s. When death results from one of the sequelae, either disease of the 
kidne} T s or paralysis, it ma} T be deferred for weeks, or even several months. 

Prognosis. — In cases of ordinary severity, when the patient is seen 
early, and the disease remains limited to the pharynx, the result is usu- 
ally favorable; though no case, not even the mildest, is free from danger, 
either of extension into the larynx or bronchial tubes, of exhaustion, or 
of the supervention of some complication, such as endocarditis, or the 
formation of heart clots. If, on the contraiy, the exudation extends to the 
nasal passages, the prognosis is more unfavorable; and when the larynx 
becomes implicated, the prognosis is exceedingly grave; if the disposition 
to the production of false membrane spread to the skin, rectum, or vulva, 
the prognosis is also very grave, and death generally occurs in a state of 
profound adynamia. 

If an}' other signs of unusual malignancy are present, such as abnormal 
slowness, or great frequency and smallness of pulse; marked prostration, 
with pallor and coolness of the surface; great tumefaction of the cervical 
glands ; abundant pseudo-membranes, pultaceous and rapidly decompos- 
ing ; hemorrhages from various mucous surfaces ; acrid, fetid discharges 
from the mouth or nostrils; intense and persisting albuminuria, with 
diminution of the amount of urea excreted ; the prognosis is, of course, 
much more unfavorable. 

It must be remembered, however, that no one of these sj'mptoms, nor 
even anj' combination of them, is necessarily of fatal import ; that cases 
are often rescued apparently from inevitably impending death; and that, 
however threatening the sjmiptoms may be, it is our duty, in this disease 
even more than in man3 r others, to persevere to the very latest moment 
in the judicious application of suitable remedies. 

It is as yet impossible to arrive at any plausible estimate of the aver- 
age mortality of diphtheria, so widely does the proportion vary in differ- 
ent epidemics. Neither sex nor temperament appear to have an y influence 



DIAGNOSIS. 615 

upon the result ; but extreme youth undoubtedly renders the prognosis 
much more grave. 

The prognosis in the secondary form of diphtheria is also more unfa- 
vorable than in the primary. 

Diagnosis. — We have already sufficiently dwelt upon the general symp- 
toms and local signs which enable us to detect diphtheria, in every in- 
stance, after the disease has full}* developed itself. 

In examining the fauces in the early stage of the affection, it is well to 
remember that in simple angina, the crypts of the tonsil glands occasion- 
ally become so distended by their secretion as to present the appearance 
of small, round, and slightly elevated whitish patches, which might readily 
impose upon a hasty observer for pseudo-membranous deposits. 

In regard to the value of the peculiarities upon which a differential 
diagnosis between diphtheritic croup and idiopathic primary membranous 
croup is so frequently based, we have fully expressed our opinion in the 
article on the latter disease, to which we would refer the reader. 

Diagnosis from Scarlatina. — The great resemblance which at times 
exists between the anginose s} T mptoms of scarlatina and diphtheria has 
led some authors to suggest that they are identical diseases, and the fol- 
lowing further points of resemblance have been adduced: the two affec- 
tions prevail frequently simultaneously in the same region, and even in 
the same family; in certain cases of diphtheria, a rash, very similar to 
that of scarlatina, is said to appear ; and the urine, in diphtheria, is fre- 
quently albuminous. That this similarity is, however, more apparent 
than real, is evident from the following considerations. 

1. Although in some epidemics of diphtheria a rash is said to have 
been occasionally noticed, its occurrence is at most the rare exception, 
instead of the almost invariable rule, as in scarlatina; it differs, too, from 
that of scarlatina, in appearing at irregular periods, in being partial, ap- 
pearing suddenly in patches, not deepening gradually in intensity, and 
in being of a uniform eiythematous redness, without the punctated ap- 
pearance peculiar to the scarlatinous eruption. 

2. The albuminuria of diphtheria presents these distinctive features as 
compared with that of scarlatina, that there is not always any diminution 
in the amount, nor any constant change in the character of the urine 
when it is present ; that it occurs in the early part of the attack, and in- 
creases as the disease approaches its height, or may disappear suddenly, 
even in the early part of its course ; that although usually noticed in se- 
vere cases (and probably a very unfavorable symptom), there seems to 
be no necessary connection between the urine becoming non-albuminous 
and the disease assuming a milder type. 

3. There is a wide difference in the sequelae which succeed the two 
affections ; dropsy scarcely ever following diphtheria, while various par- 
alytic phenomena, which are rarely noticed after scarlatina, are of frequent 
occurrence. It is very much more common, also, to have suppuration of 
the glands of the neck after scarlatina. 

In, the same way endocarditis, though it has recently been noticed in 
a few cases of diphtheria, is much more frequent in scarlatina. 



616 DIPHTHERIA. 

4. One of the most positive proofs of the essential difference of these 
two affections is the fact, attested by universal experience, that the}" exer- 
cise no protective power whatever against each other, and that individuals 
whose systems are protected against a second attack of scarlatina, are 
full}" as likely to contract diphtheria as those who have never suffered 
with either of these diseases. 

It may also be added that second attacks of scarlatina are very rare, 
while they seem to be much more common in diphtheria. 

It seems evident to us, therefore, that in the present state of our in- 
formation upon this subject, scarlatina and diphtheria must be regarded 
as entirely distinct affections, although presenting quite numerous points 
of singular resemblance. * 

Complications and Sequels. — Albuminuria. — We have already briefly 
alluded to the peculiarities of the albuminuria of diphtheria, but the im- 
portance of the symptom merits a more fall discussion. 

The occasional presence of albumen in the urine in cases of diphtheria, 
was first noticed by Mr. Wade in 185T, who also found associated with 
the albumen, tube-casts and renal epithelium. It was shortly afterwards 
recognized by MM. Bouchut and Empis 1 in thirteen out of fifteen cases; 
and since then has been found, in a varying proportion of the cases, by 
many observers in different epidemics. 

The character of the urine when it contains albumen is not constant, 
but usually it is quite pellucid, of acid reaction, and apparently free from 
any deposit ; although, on standing, both tube-casts and epithelium may 
settle to the bottom. The quantity also varies considerably, Hillier hav- 
ing found it much diminished, while, according to West and Wade, it 
frequently remains normal. 

The amount of urea excreted is usually increased in diphtheria, and, 
according to Sanderson, the presence of albumen and tube-casts in the 
urine is not necessarily associated with any interference in its elimination, 
but this does not agree with the examinations of others, who have found a 
diminution of the solid excreta when albumen was present. 

The quantity of albumen varies much, being at times a mere trace, and 
again being present in large amount. The kinds of tube-casts noticed 
by Wade, and which are the ones usually found, were small, waxy casts ; 
casts of a similar size, but granular, probably from commencing disinte- 
gration, and ordinary epithelial casts, and fibrinous flakes. 

Albuminuria in diphtheria occurs at various stages of the disorder — in 
some cases even during the first few days. It not rarely comes on insidi- 
ously, and may manifest its pres-ence by no peculiar constitutional symp- 
toms. There can be, however, little doubt of the grave import of its appear- 
ance, though as yet its exact significance has not been accurately defined. 

It is indeed true, that it has been found in large quantities in cases 
which have preserved a mild character throughout (Sanderson) ; but on 
the other hand, Bouchut and Empis regard it as a' highly unfavorable 
sign, coinciding with very great gravity of the disease ; and Wade be- 

i De l'Album. dans les Mai. Couenneuses, Compt. Eendus, 1859. 



HEART -CLOT. 617 

lieves that the quantity of albumen is usually in direct proportion to the- 
retention of effete material, and that indications of impairment of the 
renal function are almost constantly precursors of an unfavorable termi- 
nation. 

Hillier (op. tit.) examined 38 very severe cases in regard to this point, 
and found albumen present in 33, 32 of which proved fatal, while of the 
5 free from albuminuria, all recovered. 

The albumen appeared in 1 case on the fourth day, in 3 on the fifth 
day, in 2 on the seventh day, in 5 on the ninth, and in 1 each on the 
thirteenth and nineteenth days. Usually the albumen disappears from the 
urine as the severity of the symptoms diminishes, but Bouchut has known 
it to persist after convalescence, and finally produce, as in Bright's dis- 
ease, anasarca and lrydrothorax. 

Heart-clot. — The formation of coagula in the cavities of the heart during 
life has been noticed in many conditions of the system; and this terrible, 
because almost necessarily fatal accident, is now alwa} r s dreaded in the 
course of several diseases, of which diphtheria is eminently one. 

There have even been epidemics of an unknown nature, but where the 
only discoverable lesion have been enormous fibrinous concretions in the 
heart. Such epidemics have been recorded by Huxham, Chisholm, and 
recently by Armancl. 1 

The symptoms mentioned by these authors as significant of this acci- 
dent are, pain at the pit of the stomach ; difficulty in respiration ; extreme 
anxiety and restlessness ; anxious expression and depression of spirits ; 
slight, dry, and rather spasmodic cough ; the face being at times livid, and 
the surface dry and inclining to be cool, with coldness of the extremities. 
The pulse was small and irregular, and, in some of Armand's cases, an ab- 
normal murmur was detected in the heart; there was usually consider- 
able dulness over the cardiac region ; the respiratory murmur remained 
pure and quite full, and the chest normally resonant. 

In diphtheria, Dr. Richardson 2 appears to have been the first to call 
attention to the difference between these symptoms of embarrassed circu- 
lation and those of obstructed respiration, as met with in diphtheritic 
croup. 

His account of the symptoms of the former condition agrees closely 
with that given above as to the coolness and almost marbly pallor of the 
surface ; the moderate lividity of the face ; the constant restlessness and 
intense anxiety ; the feeble, quick, and irregular action of the heart, with 
a muffled character of the sounds, and in some cases an abnormal mur- 
mur. He also calls attention to a peculiar prominence of the anterior part 
of the thorax in very young children, which he believes to be strictly 
diagnostic of fibrinous obstruction. 

In obstruction of respiration, on the other hand, the surface becomes 
livid, the veins turgid, and the muscles are often convulsed ; the heart- 

1 Des Concretions Fibrineuses et Polypiformes du Coeur, 1857. 

2 Med. Times and Gaz., March 8, 1856; British Med. Jour., Feb. 16 and April 
7, 1860. 



618 DIPHTHERIA. 

sounds are clear, though feeble, and the breathing is the first to stop at 
death, instead of the circulation, as in the other case. 

In three cases occurring in the practice of one of ourselves, 1 in which we 
were able to diagnosticate the condition, death took place on the twent} 7 - 
first, twenty-fifth, and twenty-eighth days respectively. In each case the 
local sj^mptoms had given way and almost disappeared, and the children 
seemed to have entered upon convalescence, when slight but steadily 
increasing signs of circulatory embarrassment became perceptible, and 
after a few days battling against the constantly increasing obstruction, 
the little patients each died as though worn out by the unequal struggle. 

In no case was there any evidence of any other organ being implicated ; 
one of the cases was, however, complicated with albuminuria. 

The pulse was not noted to be over one hundred ; the cardiac sounds 
were unattended with murmur, but confused, indistinct, and seeming as 
though reduplicated. 

There was no marked paralysis, but in one case partial paralysis, and 
in another marked muscular debilit}^. 

At the autopsy, in each case, the right side of the heart was full of 
clots, which were either dark-colored, with whitish spots, or 3 T ellowish- 
white throughout, quite firm, and adherent to the endocardium, and ap- 
peared to have been forming for several da3 T s. In one case a clot in the 
left ventricle presented at its lower extremity a broken, irregular, uneven, 
and frayed or granulated appearance, as though the disintegrating pro- 
cess by which thrombi are broken up, had commenced in it. In none of 
the cases were there any evidences of endocarditis. The same accident 
has been observed during the past ten } T ears by Dr. Barry, 2 Mr. H. Smith, 3 
and Mr. C. K. Thompson. 4 

Most of the cases have occurred in young subjects, and the clot has 
formed late in the course of the disease, or even after convalescence has 
begun. The cause of this deposition of fibrin is not very apparent ; in 
our article on this subject, already referred to, it was suggested that the 
coagulation might depend upon some peculiar change in the tissue of the 
endocardium, analogous to that which gives rise to the diphtheritic ex- 
udation on mucous surfaces. 

No such alteration has, however, as } T et been detected, and Dr. Richard- 
son, to whom the profession is so much indebted for his investigations 
upon the coagulation of the blood, attributes it, in this case, to a de- 
ficienc} r of the volatile agent which retains the fibrin in solution, together 
with an actual increase in the amount of the fibrin of the blood, this 
combination producing the most favorable condition possible for fibrin- 
ous deposition. 

Endocarditis. — Although in the above cases no lesion of the endo- 
cardium has been found, Mr. Bridger (loc. cit.) has noticed inflammation 
of this membrane quite frequently in diphtheria. It has usually appeared 

1 r)r. J. F. Meigs, Am. Jour. Med. Science, April, 1864, vol. xlvii, p. 305. 

2 British Medical Journal, 1858. 

3 Med. Times and Gaz., Dec. 17, 1859. 



i 
PARALYSIS. 619 

late in the course of the disease, and has been attended with pain in the 
pnecordia, frequent pulse, hurried respiration, an anxious countenance, 
with in some cases a systolic murmur. In fatal cases, there was found a 
roughened, reddened, thickened appearance of the valves, as if clue to 
interstitial deposit. 

Paralysis. — One of the most frequent and important, and certainly 
the most peculiar of the sequeke of diphtheria, is the occurrence of pa- 
ralysis. It originally attracted the attention of MM. Trousseau, La- 
segue, aud Faure, under the form of difficulty of deglutition and a nasal 
character of the voice ; but since then has been observed in the most 
varied forms and degrees, affecting both general and special sensation 
and the power of motion. In most cases, every trace of the primary dis- 
ease has disappeared before airy paralysis is noticed ; the patient sleeps, 
eats, and digests well, 3'et man}' cases emaciate, and there is often marked 
pallor of the surface. In many instances also, especially in children, 
there is great irascibilitv or irritability of temper. 

Most frequently a nasal character of voice and regurgitation of liquids 
through the nose are the first S3'mptoms to call attention to the disease, 
though these may be preceded by some slight clifficuhVy in articulation, or 
by alteration of the sense of taste at the back of the tongue. On examin- 
ing the fauces the soft palate is found hanging relaxed, and, if it be pricked, 
there is no contraction of it, nor does it give the patient pain. 

At times but one side is paralyzed, and the uvula is drawn towards 
the sound side. The affection may extend no further than the fauces, and 
soon disappear; or it may advance, the eye usually becoming next affected, 
following the throat affection, and preceding any paralysis of the limbs. 
The impairment of vision is rarely of long duration, lasting from a few 
days to two months, and is of every grade from mere inabilhyy to read fine 
print to perfect blindness. 

Dr. Greenhow has noticed that the pupils become dilated, and act 
sluggishly under the influence of light, for a day or two before the sight 
becomes sensibly impaired, and may remain so for a time after sight has 
been regained. He has also observed that patients who were unable to 
read with unassisted sight could do so with the aid of convex glasses, so 
that he attributes the impairment of sight to paralysis of the ciliary 
muscle and temporary loss of the adjusting power. 

In addition to this want of accommodation, however, depending on 
paralysis of the ciliary muscle, Bouchut believes that there is in many 
cases, and especially in those who have had albuminuria, a serous infiltra- 
tion of the fundus of the eye, due to the anaemic condition of the blood, 
and which may impair the nutrition of the optic nerve, and even lead to 
its atrophy. 

Deafness may follow this amaurosis ; then the lower limbs become af- 
fected, the patient becoming paraplegic, and next the upper extremities ; 
then the muscles of the alimentary canal and bladder, causing impaction 
of the rectum with faeces and retention of urine, or the sphincters of 
these organs alone may be involved, and lead to involuntary discharges. 
Finally, the muscles of the trunk, including those of respiration, may be- 



620 DIPHTHERIA. 

come paralyzed, and in some very rare cases even the muscles of the 
heart are involved. It is stated that the paralysis of the extremities is 
never strictly unilateral. The paralysis is rarely confined to loss of mo- 
tion, but, in a majority of cases, sensation is either much modified or 
lost ; and indeed in some instances there has been no loss of motion, the 
sentient nerves alone being affected. In other cases the sensibility has 
been found exalted, or there has been in the same case hyperesthesia in 
the upper, with anaesthesia in the lower extremities. 

The paralysis, whether it be of motion or sensation, is progressive and 
gradual, even in the same set of muscles, and usually involves one limb 
before it extends to other parts. The mind, though often feeble and dull, 
acts correctly in most cases. 

During the continuance of these phenomena, the appetite may remain 
good and digestion esisj ; but there are often marked evidences of the 
continuance of some morbid agent in the economy. The surface is of 
an earthj^, sallow hue, calorification is often imperfect, and the circula- 
tion is much depressed, the pulse being small, weak, and much reduced 
in frequency. 

In some cases, indeed, the affection runs on to a fatal issue, usually 
consequent upon a failure of one of the vital functions of circulation or 
respiration. M. Faure has given a vivid picture of these sequelae in their 
worst form, when the patient, paralyzed, indescribably prostrated, with 
imperfect speech and power of deglutition, impaired vision, imbecility of 
mind, oedema, and even gangrene of the extremities, finally dies in some 
fainting fit, or passes away almost imperceptibly. 

The result of diphtheritic paraly sis is, however, favorable in a large 
majority of cases ; thus of 1*1 cases collected by Dr. Reynolds, but 9 were 
fatal. The duration is, however, more uncertain, varying from one or 
two weeks to several months, the mean duration being about a month. 

It is as yet impossible to advance an} 7 satisfactory explanation of the 
cause of these grave paralytic sequelae. They occur probably in one- 
fourth of all cases, in greater or less degree, and are noticed with at 
least equal frequency after mild as after severe attacks. 

At first, indeed, the faucial paralysis was attributed to some such local 
cause as inflammation of the sheath of the nerves supplying these parts, 
and Greenhow still contends that the nerve affections bear some propor- 
tion to the local severity of the attack, the paralysis and anaesthesia being 
more complete on that side of the fauces which has been most severely 
affected by the primary disease ; but we have been able to satisfy our- 
selves that this does not occur with any uniformity. 

Nor is the occurrence of albuminuria necessary for the development of 
paralysis, since the urine is often quite normal throughout the entire 
course of cases, which are nevertheless followed by marked palsy. 

The most plausible view we can entertain of the nature of these nerve 
affections, is that they are the direct effect of the diphtheritic poison, 
which, while modifying the blood crasis, and so acting on the system at 
large, has an especial tendency to the nervous system. 



LOCOMOTOR ATAXIA — LOCAL TREATMENT. 621 

Ataxic Form. — In some cases, which are comparatively rare,' the nerve 
affection does not constitute actual paralysis, but takes the form of loco- 
motor ataxia. In such cases, the muscular force in the affected parts, 
usually the lower extremities, is not materially diminished, so that the pa- 
tient can move them forcibly when he is lying down ; but there is such a 
degree of incoordination in the motions communicated to them, that 
combined movements, even in the supine position, may become impossi- 
ble. It is. however, especially in walking, that this loss of co-ordinating 
power manifests itself, the gait becomes irregular, the patient falls if the 
eyes are closed, and the case presents all the characteristics peculiar to 
well-marked locomotor ataxia. 

The first instance of this diphtheritic ataxia appears to have been ob- 
served by Jaccoud 1 in 1861; it was soon after noticed by Eisenmann ; 2 
and more recently a well-marked case has been reported by Dr. Gray, 3 in 
a boy of nine years old, following an apparently mild case of diphtheria. 
It is evident, also, as pointed out by Jaccoud, that a certain number of 
the cases which have been reported under the name of diphtheritic paraly- 
sis, have in reality been examples of locomotor ataxia, the paralysis having 
been onl} T apparent. This diphtheritic ataxia is in all probability due to 
the same unknown morbid condition or clvscrasia, which causes the ac- 
tual paralytic symptoms which are more frequently observed as sequelae 
of diphtheria. It usually yields to the treatment recommended for the 
latter conditions, though in Gray's case, death occurred, apparently from 
rapid loss of nervous power, seven weeks after the appearance of the ner- 
vous symptoms. 

Treatment. — The treatment may be usefully considered under the two 
heads of local and general. Of late years, the importance of the latter has 
been more and more recognized as supreme, and, indeed, the utility of all 
local treatment has been questioned on the ground that the throat affec- 
tion is merely a local evidence of the constitutional disease, and that the 
disease rarely kills save by involving organs beyond the influence of such 
agents. Still, on the other hand, there are eminent authorities, as Trous- 
seau, who assert that topical applications are the most successful and 
important remedies in diphtheria. 

The great objects to be held in view in the local treatment, are to favor 
the separation of the pseudo-membranes, and to prevent their extension 
from the fauces into the larynx and nasal passages. 

Local Treatment. — The most important of the local remedies are in- 
cluded in the lists of astringents and caustics. 

Of these, nitrate of silver has probably been used more than any other 
substance for many years past, and is highly recommended by MM. Bre- 
tonneau, Yalleix, Grisolle, Rilliet and Barthez, Trousseau, West, and 
many others. 

It is employed both in solution and substance. The latter form is, 

1 Les Paraplegie6 et l'Ataxie du Mouvement, p. 631, Paris, 1864. 

2 Die Bewegungs Ataxie, Wien, 1863. 

3 London Med. Times and Gazette, February 6th, 1869, p. 141. 



622 DIPHTHERIA. 

however, open to the objections, that if the extent of the false membranes 
be at all considerable, the solid caustic can seldom be applied to more 
than a small portion of it, and that it is attended with the risk of slipping 
from the porte-caustic into the pharynx, and thence passing into the stom- 
ach. 1 The solution is therefore generally preferred. M. Bretonneau ad- 
vises its employment in the proportion of half an ounce of the salt to an 
ounce and a half of water ; and West employs a solution of the strength 
of a drachm to an ounce. 

We have usually made use ourselves of a solution of ten or twenty 
grains to the ounce, and have found it abundantly strong. It may be 
applied either by means of a piece of sponge fastened upon a proper 
handle, which is the best method, or a camel's hair pencil, nearly as large 
as the end of the little finger. The application should be made once, 
twice, or even three times in the course of the twenty-four hours. 

Hydrochloric acid is also frequently employed, either pure or diluted 
with from one to ten parts of honey ; the more dilute forms being used in 
the case of children. 

It possesses the great advantage over the other mineral acids, that its 
caustic action does not extend much from the point of application, but is 
open to the objection of causing a white plastic exudation on any part of 
the mucous surface, not covered with false membrane, with which it may 
come in contact, which may lead the physician into error. 

When the limits of the pseudo-membrane can be seen in the pharynx, fol- 
lowing M. Bretonneau's advice, the acid ma}^ be used more concentrated, 
and the sponge, after being dipped into the acid and squeezed so as to 
be merely moistened, should be carried rapidly into the pharynx, and 
withdrawn after lightly cauterizing the surface. 

When, on the contrary, the limits of the membrane cannot be seen, the 
acid should be more diluted, and leaving more of it upon the sponge, this 
should be passed down over the epiglottis and then pressed against the 
base of the tongue, by raising strongly the handle to which it is tied, in 
order to express a few drops upon the mucous membrane of the larynx. 
The cauterization is to be performed once or twice a day, according to 
the necessity of the case. For children under ten j^ears of age, the sponge 
ought to be about half as large as a pigeon's egg. It is to be fastened 
to a piece of flexible whalebone, by making a crucial incision into it, 
introducing into this the end of the whalebone, and securing it with good 
sealing-wax, which is not acted upon bj r the acid as any ligature would 
be. When about to be used, the whalebone is warmed and curved into 
such a shape as will allow it to pass into the phaiynx without touching 
the roof of the mouth. M. Talleix proposes that the sponge should be 
fastened to the whalebone with waxed thread, and that this should be 
covered with sealing-wax, to preserve it from the action of the acid. This 
would certainly be safer than the mere wax itself. 

1 Dr. Geddings recommends, when it is desirable to use the solid nitrate, to reduce 
it to powder, and to roll the sponge probang, previously moistened with mucilage of 
gum arable and squeezed, in the powder until a sufficient quantity adheres, and to 
apply it thus prepared to the diseased parts. 






LOCAL TREATMENT. 623 

Applications of powdered alum, tannic acid, and chlorinated lime, are 
recommended by writers of high authority. In slight cases, in which the 
disease shows but little disposition to extend, such applications may an- 
swer very well ; but when the attack is threatening, and especially when 
the exudation is spreading, we should neglect these minor remedies, and 
resort at once either to nitrate of silver, dilute muriatic acid, or the 
tincture of the chloride of iron. If, however, these powders are em- 
ployed, the\ T may be applied by means of a throat brush, or by causing 
a sufficient quantity to adhere to the forefinger of the right hand, and 
conveying it upon this to the diseased surfaces. 

The astringent and caustic preparations of iron have lately been intro- 
duced in the treatment of this affection with much benefit. They cause 
the pseudo-membranes to contract and shrivel, and thus favor their sepa- 
ration, while at the same time they modify the action of the mucous mem- 
brane, and also tend, as does the sol. sodas chlor., to correct the fetor 
arising from the putrefaction of the false membranes, and to prevent poi- 
soning of the s} r stem by- absorption. 

The tr. ferri chloricli and the ferri perchloridum are among the best 
preparations, and may be applied, either pure or diluted, several times in 
the course of twenty-four hours. Monsell's salt, in powder, has also been 
highly recommended by Beardsley, of Connecticut, and possesses the 
same mode of action, though somewhat more escharotic. 

Carbolic acid, diluted with glycerine and water, applied by a mop to 
the throat, appears to possess almost equal virtue in causing the separa- 
tion of the pseudo-membranes, and preventing their re-formation. 

Various applications have also been recommended from the fact that 
they exercise a direct solvent power over the pseudo-membranes, and 
thus promote their removal. Among those which have been thus recom- 
mended are solutions of lime, potassa, and soda; solution of chlorinated 
lime; of chlorate of potash or soda ; of permanganate of potash; of bro- 
mide of potassium ; of pepsin ; and of dilute lactic acid. 

Dr. Jacobi (Amer. Jour, of ObsteL, May, 1868, pp. 13-65), has pub- 
lished an analysis of the relative value of these solvent applications. 
According to him, lime-water requires four to ten hours to thoroughly 
liquef}' soft diphtheritic exudation ; while for firm pseudo-membranes, it 
requires from thirty to seventy-two hours. Potash and soda, and their 
salts, act more slowly; and the one other application which he recom- 
mends as equally rapid in its action is a solution of bromine gr. i, bromide 
of potassium gr. i, in f3vi of water. 

We have carefully tested the latter solutions, as well as those men- 
tioned above, and from the results of repeated tests, have concluded 
that lime-water is the most powerful in its solvent action upon pseudo- 
membranous exudations. We have frequently found, when fragments of 
firm white exudation have been placed in lime-water at a temperature 
even lower than that of the buccal cavity, that the exterior began in a very 
short time (half an hour) to undergo disintegration, and that the whole 
fragment was reduced in a few hours to a granular putrilage. It is, how- 



624 DIPHTHERIA. 

ever, undoubtedly true that this effect will be produced with very differ- 
ent rapidity upon different specimens of pseudo-membrane. 

There is no real difficulty in making use of airy of these applications, 
if the children be properly managed. One or two assistants must hold 
the patient in such a way that the head shall be thrown backwards, and 
the hands and feet secured. The physician must depress the tongue 
with the handle of a spoon held in the left hand, while he holds in the 
right the pencil or sponge mop. If the child refuse to open the mouth, 
it can generally be made to do so by holding the nose in order to force it 
to breathe through the mouth. If this fail, all that is necessary is to 
press the handle of the spoon against the teeth, when the patient will soon 
become too much fatigued to offer further resistance. 

Gargles. — When the patient is sufficiently old and intelligent to be 
able to use gargles thoroughly, any of the substances which have been 
recommended as local applications may be thus used, being of course 
largely diluted. Thus tr. ferri chl., hydrochloric acid, sol. soclse chlori- 
nate, in the proportion of fji or f3ii to f^vi, or chlorate of potash in 
strong solution, may be used as gargles with much advantage in some 
cases. 

These solutions may also be very efficiently applied to the throat in a 
finely divided condition, by means of the steam or hand-ball atomizer ; 
a mode of application which is peculiarly useful in cases where the pseudo- 
membrane has extended to the laiynx. 

A very convenient and ready application, and one from which we have 
obtained marked advantage in several cases, especially where the exuda- 
tion had extended to the larynx, is by covering the patient's head with a 
sheet, and introducing a vessel containing slaking lime, so that the steam 
may be freely inhaled. It is probable that the chief benefit is here derived 
from the warm watery vapor ; though a small quantity of lime, in the form 
of impalpable powder, probably gains entrance to the fauces and air- 
passages. 1 

Ice. — In a rather early stage of the disease, if there is much heat and 
engorgement about the throat, cold, wet compresses may afford tempo- 
rary relief; and great benefit is often obtained in cases where there is 
much swelling and inflammation of the fauces and pharynx, by the free 

1 Bouchut has lately strenuously advised active cauterization of the fauces, or abla- 
tion of the tonsils, not only for the purpose of removing the exudation which appears 
on them, which he considers the localization of the disease, but also of facilitating 
respiration. 

According to him, the operation of ablation has now been performed fifteen times, 
five by himself and ten by MM. Domere, Symyan, Speckahn, and Paillot, with suc- 
cessful results in each case, no false membrane reappearing. 

Despite this favorable report, however, the procedure appears to us objectionable, 
regarding, as we do, the importance of the local condition as secondary to that of the 
alteration of the blood. The operation must further cause the greatest alarm and 
most powerful resistance on the part of young children, and it seems highly improb- 
able that a large proportion of cases should be attended with the same fortunate ex- 
emption from a recurrence of pseudo-membranous formation, as occurred in Bouchut's 
cases. 



GENERAL TREATMENT. 625 

internal use of ice, allowing the patient to hold small pieces of it almost 
constantly in the month. 

Other external applications may also be employed to reduce the swell- 
ing of the cervical and submaxillary glands, render deglutition more easy, 
and relieve suffering ; and, in this way, the persistent use of poultices or 
spongiopiline fomentations are of service. 

It is essential to remember, however, that all blisters, or irritating appli- 
cations capable of destroj'ing the epidermis, must be carefully avoided, 
owing to the tendencj^, already alluded to, of the pseudo-membranous 
deposit to occur on such abrasions. 

When the nasal fossae have become implicated from extension of the 
pseudo-membrane, one of the dilute solutions recommended as gargles 
should be injected through the nostrils, or the desired effect may be even 
more thoroughly secured by the use of the same fluid through a Thudi- 
chum's nasal douche. 

General Treatment. — Whatever differences of opinion may exist in 
regard to the relative merits of the various local applications we have 
enumerated, all high authorities are now agreed as to the general charac- 
ter of the constitutional treatment which should be adopted. 

Some years ago, before opportunities had been presented for studying 
diphtheria in its epidemic form, as it has since occurred, it was custom- 
ary to employ moderate depletion early in the attack, if the patient was 
vigorous and strong, and to follow this by the use of mercury and anti- 
phlogistics, with a view of subduing the febrile excitement, and causing 
the dissolution and absorption of the pseudo-membrane. 

With the increase of knowledge, however, of the true pathology and 
natural history of the disease, which has been gained of late years, all 
depleting and antiphlogistic plans of treatment have been, by common 
consent, abandoned as indefensible either in theory or practice, and all 
efforts are directed to promoting the nutrition of the patient and sup- 
porting the strength of the system, as indicated by the marked tendency 
to prostration, the feeble pulse, and the manifest deterioration of the 
blood. 

It is probable that those cases in which bloodletting and the adminis- 
tration of mercurials were adopted with such apparent benefit, were either 
erroneously considered diphtheritic, or that the disease, when occurring 
sporadically, as it formerly did, was of a far more sthenic type than it 
has presented of late years. 

Regarding diphtheria as a constitutional affection, depending upon a 
peculiar alteration of the blood, we must admit that we are in possession 
of no remedy which in any respect merits the name of a specific in its 
treatment. 

Among the best internal remedies, however, are the various prepara- 
tions of chlorine, iron, and bark, which may be given singly, or, preferably, 
in combination. 

Thus there are no remedies of more uniform and marked advantage 
than sulphate of quinia and tincture of the chloride of iron, given in full 
doses at short intervals. Hydrochloric acid or chloric ether may be added 

40 



626 DIPHTHERIA. 

to these tonics, and this combination is strongly recommended by West 
and other high authorities. 

The Sanitary Commission, in London, reported very strongly in favor 
of a mixture containing tincture of the chloride of iron, with chlorate of 
potash, chloric ether, and hydrochloric acid, sweetened with syrup; full 
doses being employed according to the age of the patient, and frequently 
repeated. This combination has been, by Gribb, rendered still more stimu- 
lating b} T the addition of muriate of ammonia. 

Oil of turpentine has been recommended (Dr. Perrey, Med. Times and 
Gaz., March 5th, 1859) in large doses, both for its stimulating effect, and 
from its tendenc} T to promote the absorption of lyraph in adynamic states 
of the s3 T stem, where mercury cannot be given. 

Chlorate of potash, given in Huxham's tincture of bark, has been 
vaunted as almost specific in the treatment of diphtheria; but, as re- 
marked b} 7 West, it unquestionably fails to produce here those excellent 
effects which are obtained from its use in ulcerative stomatitis. 

Permanganate of potash, which has been so extensively used of late 
years in zj^motic diseases, has been used both locally and internally in 
this affection, but apparently without any very positive advantage. 

Emetics; Purgatives. — Emetics are useful when the exudation shows a 
disposition to extend to the larynx, or when there is much difficulty of 
breathing from tumefaction of the fauces, or from accumulation of the 
pseudo-membranous deposits. We would recommend under these cir- 
cumstances the use of alum or ipecacuanha, as recommended in the ar- 
ticle on pseudo-membranous laiyngitis ; the emetic being repeated in six 
or twelve hours, if the same indication should continue or recur. 

A purgative dose is useful at the commencement of the disease, merely 
as an evacuant. After that period only such laxatives need to be em- 
ployed as may suffice to keep the bowels soluble. 

Stimulants. — In the milder forms of diphtheria, where no complica- 
tions exist, the cases usually terminate favorably without the use of 
any stimulants; but there are many cases, on the other hand, character- 
ized b} T pallor of surface, marked weakness of the circulation and ten- 
denc} T to prostration, great enlargement of the cervical glands and 
extensive disease of the throat, where the pseudo-membranes rapidly 
decompose and assume a gangrenous appearance, and the urine is fre- 
quently albuminous, in which stimulants, freely administered, are posi- 
tively required. 

In cases where such adjmamic symptoms are present, we should begin 
early in the attack with the administration of the weaker stimuli, and 
employ the stronger forms as the disease advances and the strength of 
the s3 T stem succumbs more and more. 

Food. — In no disease should more sedulous care be paid to securing to 
the patient a proper amount of suitable nourishment ; and, indeed, in the 
absence of any remedy which can be looked upon as essential or specific, 
we must assign, perhaps, the most important part in the treatment of 
diphtheria to food and stimulants. It is at least certain that where these 
cannot be administered in proper quantity, all other treatment is unavail- 



TREATMENT OF PARALYSIS AND HEART -CLOTS. 627 

ing. and hence it is our duty, upon finding that the pain and fatigue ex- 
perienced by the child when forced to take frequent doses of medicine 
make it utterly unwilling to take food, to abandon all strictly medicinal 
treatment, and trust to sustaining the powers of the system by the free 
use of stimulants and concentrated food. 

In cases where mechanical obstruction exists, or where all efforts at 
voluntary deglutition are obstinately resisted from fear of the great pain 
caused by the act, nutritious and stimulating enemata must be imme- 
diately resorted to. These may consist of beef-tea, eggs beaten up in 
milk, brandy in the form of milk-punch, and, further, may be medicated 
by the addition of quinia. They should be given every three or four 
hours, in rather small quantity, and not so concentrated as to irritate 
the bowel. When thus administered it is quite possible to sustain life 
for several days, until food can again be introduced into the stomach. 

In addition to the local and general treatment above recommended, 
the patient should be rigorously confined to bed during the whole treat- 
ment, and for at least ten days after the disappearance of the exudation. 
This caution is given, not only on account of the danger of that most 
fatal accident, the formation of a heart-clot, but because we have twice 
known the exudation to reappear when the patient has been allowed to 
leave the bed at too early a period ; and in one of these the exudation ex- 
tended into the laiynx on the occasion of the second attack, in spite of 
all that could be done, and life was saved only by the operation of trache- 
otomy. 

The most scrupulous cleanliness of the person and surroundings of the 
patient should be preserved ; free and uninterrupted ventilation secured ; 
and on account of the positive, though perhaps slight, contagiousness 
of diphtheria, it is wise to practise separation of the well children in the 
family from the sick. 

The treatment required in those cases where the pseudo-membrane ex- 
tends into the larynx, and especially the discussion of the indications for 
the operation of tracheotomy, will be found in detail in the article on 
pseudo-membranous laryngitis. 

Treatment of Paralysis. — We have already stated that the prognosis 
in diphtheritic paralysis is usually favorable, the symptoms often dis- 
appearing in the course of time without treatment. The cure may, how- 
ever, be much hastened by a persistence in the administration of iron 
and quinia, to which strychnia may advantageously be added. 

Nitrate of silver has also been employed in full doses with apparent 
benefit. 

The paralyzed muscles should be faradized daily ; and, when accessible, 
sea-bathing or sulphur baths may be employed with advantage. 

In those cases where the muscles of deglutition are especially affected, 
and the nutrition of the patient is suffering from his inabilit}- to swallow 
sufficient food, it is desirable to resort to the use of nutritious enemata. 

Treatment of Heart- Clots. — Under the supposition that the blood is 
hyperinotic in the latter stage of diphtheria, the various salines, especially 
the vegetable ones, such as the citrates and acetates, and ammonia, given 



628 mumps. 

either as the carbonate or in the liquid form, have been recommended by 
Richardson. 

When, however, the sj'mptoms indicate that deposition of fibrin has 
absolutely occurred, it is probable that nothing can be done in the way 
of curative treatment. Alkalies may be given internally, the vapor of 
ammonia inhaled, alkaline solutions injected into the veins, but there is 
little reason to hope that an} T effect upon the clot can be produced. 

In one of the cases reported by us {Joe. tit.), the clot presented at one 
extremity a granular, partially disintegrated condition, as though its re- 
moval had begun by interstitial action, and the mechanical effects of the 
blood current ; and it is possible that by supporting the powers of nature 
the removal of the clot might be effected in this way. 



ARTICLE III. 

MUMPS. 

Definition ; Synonymes ; Frequency. — Mumps is an acute febrile spe- 
cific disease, contagious and epidemic ; occurring but once in an indi- 
vidual ; attended by an inflammation of the parotid and sometimes of the 
submaxillary glands, with a tendency to metastasis to the testicles in 
males and to the mammae, vulva or ovaries in females ; and almost invari- 
ably resulting in recoveiy. 

Some authors, as Memeyer, object to classifying mumps with constitu- 
tional diseases ; but the fact that it undoubtedly possesses the features 
enumerated in the above definition, and which, in the present state of our 
.knowledge, must be regarded as specifically characteristic of that class 
of affections, seems to us to fully entitle it to be included with the other 
general diseases. 

Mumps is known under a variety of names in eve^ language. The 
terms usually employed to designate it by English and American authors 
are cynanche parotidea, parotitis, parotiditis, and inflammation of the 
parotid. 

It will be impossible to obtain any definite idea as to the frequency of 
this affection, until the system has been introduced of registering not 
merely deaths but all cases of disease, since mumps is scarcely ever fatal. 
Its frequency is, however, known to vary very widely in different years, 
owing to epidemic influences ; so that while in certain years we do not 
meet with a single case, in others we are called to a considerable number. 

Causes.— Nothing is known in regard to the essential nature of the 
cause of mumps. The disease is, however, unquestionably contagious, 
and it quite rarely happens that one member of a family sickens with 
mumps, without some of the other children being attacked. 

Mumps rarely occurs as a sporadic affection, but appears, as already 
stated, in epidemics of varying extent and severity, at times being 



ANATOMICAL APPEARANCES — SYMPTOMS. 629 

limited- to a single locality or even a single institution, and at others 
affecting large cities or districts. 

Season appears to exert a powerful influence upon the development 
and activity 'of the specific poison of mumps, since the epidemics occur 
nearly always in the spring or autumn. According to Yogel, it is said to 
be endemic on the damp coasts of Holland, England, and France. 

Age also exerts an unquestionable influence, by modifying the suscep- 
tibility to the contagion of mumps. Thus the disease is far most common 
between the ages of seven and fifteen years ; whilst it is almost unknown 
before the end of the first year, comparatively rare between the ages of 
one and five years, and, on the other hand, quite rare in adults. 

Although it appears certain, however, that the susceptibility to the con- 
tagion of mumps diminishes with each succeeding year after the age of 
fifteen, we must in great part explain the rarity of the disease in adult 
life, hy the fact that a large proportion of people have had it in child- 
hood, and are thus protected against a second attack. 

Second attacks of mumps are indeed of extreme rarit} 7 . 

Anatomical Appearances. — Opportunities very rarely occur for the 
examination of the parotid glands in mumps, since this disease is scarcely 
ever fatal. Tirchow, 1 who has shown that, in cases of symptomatic sec- 
ondaiy parotitis, the affection starts in the gland-ducts, maintains that 
the idiopathic form occupies the same seat. Bamberger, 2 on the other 
hand, states that the whole gland appears enlarged and reddened, with 
its tissues swollen and flaccid, owing to an interstitial exudation of lymph. 
The softness and indolent character of the swelling, however, the fact 
that it usually extends be3'ond the borders of the gland, and its usually 
rapid and complete subsidence, all induce us to believe rather that there is 
slight catarrh of the^lucts, with mere oedema of the interstitial and sur- 
rounding connective tissue. 

It is only in rare and very severe cases that there is sufficient lymph 
effused to undergo organization and lead to persistent increase in the 
size of the gland, or to so compress the ducts as to induce atrophy of the 
true gland tissue. In even more rare cases, it is said that suppuration 
may occur. 

Symptoms. — In some cases the attack of mumps is preceded for a day 
or two by slight prodromes, consisting of restlessness, feverishness, loss 
of appetite or vomiting ; in excitable children, symptoms of nervous dis- 
turbance may occur. More frequently, however, the local symptoms 
appear simultaneously with the fever, and we have generally found posi- 
tive swelling of the parotid gland upon our first visit to the child. 

The earliest local symptom is often pain, complained of under the ear 
and increased by pressure and hy all movements of the jaw, as in masti- 
cation. There is also stiffness felt in opening the mouth. The swelling- 
appears first immediately beneath the ear ; the depression between the 
mastoid process and the ramus of the jaw quickly becomes filled, and the 
swelling rapidly extends on to the cheek and neck. At first the swelling 
is flat, indurated, and presents the outlines of the parotid gland ; but 

1 Quoted by Niemeyer (op. cit., vol. i, p. 436). 

2 Quoted by Yogel (op. cit., p. 113). 



630 MUMPS. 

it soon becomes prominent, the most marked projection usually being 
observed immediately anterior to the lobe of the ear, and extends bej^ond 
the limits of the affected gland. The central part of the swelling, corre- 
sponding to the parotid, remains firm, indurated, and more or less 
elastic, while at the periphery it is softer and often pits on pressure. 
The degree of enlargement varies much in different cases, being at times 
moderate and confined to the parotid region, while in other cases it ex- 
tends over a large part of the neck and face, and may be so great as, 
especially when both glands are affected simultaneously, to give to the 
head and neck a pyramidal shape. 

Quite frequently the submaxillary glands are involved, and the swell- 
ing consequently extends along the base of the jaw; in more rare cases, 
the enlargement is most marked in this region, or, indeed, the sub- 
maxillary glands may be almost exclusively the seat of the affection. 

The skin over the seat of enlargement is at times scarcely altered in 
color, or may present more or less marked redness. There is usually 
only very moderate tenderness on pressure. The pain suffered during 
the attack varies greatly ; in some cases it is merely a marked sense of 
tension and pressure, while in other instances, it has been complained of 
as constant and severe, and extending even to the chest and shoulders. 
The movements of the head are impaired, and those of the jaw are im- 
peded to such an extent that the mouth can only be slightly opened, and 
mastication is performed imperfectly and with great difficulty. 

Usually the swelling increases for from three to five days, remains at its 
acme for a day or two, and then rapidly subsides, so that in about ten 
days the face has regained its natural appearance. 

Mumps usually involves both parotids, though they rarely become 
affected simultaneously ; the left gland is said to be most frequently the 
first inflamed, and subsequently, in twenty-four or forty-eight hours, or 
even when the swelling has disappeared from the side first affected, the 
opposite gland becomes enlarged. Occasionally the enlargement does 
not undergo complete resolution, and a circumscribed, painless, hard 
swelling remains for a variable time in the parotid region. In very rare 
cases, suppuration is said to have occurred. The salivary secretion is 
variously affected, and may be either diminished or excessive, or remain 
unaltered. Occasionally the external swelling is associated with enlarge- 
ment of the tonsils and oedema of the submucous tissue of the pharynx. 
In such cases the difficulty of deglutition is much increased, and there 
may even be marked obstruction to respiration. 

General Symptoms. — Usually the constitutional disturbance in mumps 
is but slight and subsides even before the swelling of the parotid gland. 
Until the disease reaches its height, however, there is fever with heat and 
dryness of the skin ; the pulse and respiration are accelerated, the ap- 
petite impaired or lost, and the thirst usually extreme. There may also 
be, especially in nervous children, marked restlessness, sleeplessness from 
the pain and discomfort caused by the great swelling of the neck and 
face, and even mild delirium at night. As already mentioned, however, 
these febrile symptoms usually disappear about the fifth or sixth da} r . 



PROGNOSIS — DIAGNOSIS — TREATMENT. 631 

One of the most curious features in parotitis is the tendency which 
occasionally exhibits itself to metastasis. The parts which are liable to 
be thus secondarily inflamed are the testicles and scrotum in males, and 
the mamma?, the vulva, and the ovaries in females. The most frequent of 
these metastatic inflammations in mumps is the affection of the testicle, 
which is much more common in men than in boj^s, is usually seated upon 
the same side with the enlarged parotid, and is attended with enlarge- 
ment of the bod}' of the testicle, serous effusion into the tunica vaginalis, 
and oedematous swelling of the scrotum. The swelling of the parotid 
ordinarily subsides when any of these metastatic affections appear, but 
occasionally the two inflammations continue together, a circumstance 
which shows, as Niemeyer points out, that they are in realhVy due to a 
common cause, and that no true transference of inflammation takes place 
from one point to the other. In some instances, the swelling of the 
parotid subsides a variable time before the development of the metastatic 
affection, and, during the interval, alarming symptoms of depression and 
cerebral disturbance have been noticed, and at times referred to a metas- 
tasis to the membranes of the brain. There is, however, no actual men- 
ingitis present, and upon the redevelopment of the external swelling, 
these nervous symptoms disappear. 

Prognosis; Duration; Course; Termination. — Idiopathic parotitis 
or mumps almost invariably terminates favorably. The duration of the 
case varies from four or five days in very mild cases, to ten or twelve in 
severe ones. As alreacby stated, the inflammation usually terminates in 
complete and rapid resolution. In some cases, however, a larger amount 
of lyrnph is formed in the interstitial tissue of the gland, undergoes par- 
tial organization, and causes a hard, painless swelling, which persists for 
some time. In some epidemics, suppurative degeneration of the gland 
has been noticed, and the abscess which formed has either opened out- 
wardly or into the external auditory meatus. 

Diagnosis. — The acute febrile character of the affection, and the pecu- 
liar seat and shape of the swelling, always serve to render the disease 
readily recognizable. 

Treatment. — As mumps almost invariably runs a favorable course, the 
treatment should be of a mild and expectant character. 

The child should be strictly confined to bed ; the diet should be fluid, 
partly on account of the great difficulty in mastication, light and diges- 
tible, consisting chiefly of preparations of milk and light animal broths. 
The only internal remedies required are febrifuges, such as spirit of 
nitrous ether and solution of acetate of ammonia, with a free supply of 
water and acidulated drinks ; occasional laxatives ; and, if there is sleep- 
lessness, small doses of Dover's powder or some other anodyne. 

Local applications appear to have little or no influence upon the course 
of the swelling. The only ones to be recommended are warm, ligiit poul- 
tices, or light water-dressings covered with oiled silk, which do not annoy 
the child, and tend to favor resolution. If the induration be marked and 
extensive, so as to threaten suppuration, it has been advised to apply a 
few leeches behind the angle of the jaw. If it should become evident 



632 RICKETS. 

that suppuration has occurred, the abscess should be opened immediately, 
and the discharge favored by the application of poultices, in order to pre- 
vent further destruction of the gland or perforation of the external audi- 
tory meatus. In cases "where induration and enlargement of the gland 
persist, absorbent applications, such as inunctions of iodine or mercury, 
should be made over the tumor. 

In cases where alarming symptoms of depression and cerebral disturb- 
ance make their appearance after the sudden subsidence of the parotid 
swelling, the effort may be made to redevelop the external inflammation 
by stimulating applications to the surface, and by the internal adminis- 
tration of nervous and diffusible stimulants, such as ammonia, musk, or 
brandy. 

After the acute s3 T mptoms of the attack have subsided, and the child 
has fully entered upon convalescence, we would caution against allowing 
it to leave bed too soon, since we have occasionally observed such prema- 
ture exposure to be followed by marked febrile sequelae. Thus in one 
case, occurring in an adult, there was marked fever lasting for a week ; 
in another case, in a child, there was high fever for ten da} T s ; and in 
a third case, also in a child, there was most obstinate and violent vomit- 
ing for four days; so violent, indeed, that we feared lest some renal 
complication might have been developed; on examination, however, the 
urine was found to be entirely normal. 



AKTICLE IV. 



RICKETS. 



Definition ; Synonymes ; Frequency. — Eickets is a constitutional dis- 
ease peculiar to childhood, which first manifests itself by various disturb- 
ances of nutrition, and later by a specific alteration in the bones. 

This disease has been known under a vast variety of names in many 
different languages ; x almost the only terms by which it is designated by 
English or American authors, however, are rickets and rachitis. 

It is not without surprise that we have read the statements published, 
especially hy English authors, in regard to the frequenc}^ of this disease. 
Thus Sir TV. Jenner, whose lectures upon this subject (loc. cit.) present 
the most original, philosophical, and lifelike description of the disease to 
be found in medical literature, speaks of it as " without question the most 
common, the most important, and in its effects the most fatal of the dis- 
eases which exclusively affect children." Hillier, at the close of an excel- 
lent chapter upon rickets (Joe. cit.), presents a table showing the propor- 
tion borne by the number of cases of this disease to the total number of 
out-patients treated at the Hospital for Sick Children, London, from 

1 For Synonymy, see Art. Eickets in Keynolds's Syst. of Med., vol. i, p 768. 



SYMPTOMS AND FREQUENCY. 633 

which we calculate that of 128,656 children treated during thirteen years 
(1854-66), not less than 8419, or 6.5 per cent., were rachitic ; and in some 
years the proportion of such patients rose as high as 9 per cent. 

In describing the symptomatology of rickets we shall have occasion to 
show how varied are the degrees and forms in which it manifests itself, 
and doubtless many of the cases tabulated by Hillier presented but a 
slight degree of severity. Even with this explanation, however, we can- 
not avoid the conclusion that rickets must be a vastly more common af- 
fection among the poorer classes in London than among the same classes 
in our large American cities; nor can we say that our own experience 
agrees with that of Jenner, who further says that he has "very often 
seen it in the children of the wealthy." It is at least gratifying to be- 
lieve that our experience represents the true state of the case ; to be- 
lieve that, owing to the better accommodations and larger size of the 
houses, the better quality and the greater abundance of the food of the 
lower classes in American cities as compared with European or English, 
we escape to a great extent the ravages of this fatal disease. 

On the other hand, it is probable that the slighter degrees of rickets 
ma}^ quite frequently present themselves and be overlooked, owing to the 
comparative neglect with which this important subject was, until very 
recently, treated in works upon diseases of children. 

The fact that during the past nine years the mortality returns of this 
city contain but two deaths reported as from rickets, is of little impor- 
tance, since so rarely is it assigned as a cause of death even in Great 
Britain, that the Registrar-General has not found it necessary to devote 
a column of his tables of mortality to the disease. " The secondary dis- 
eases," as Hillier sa} T s, " are recognized, such as bronchitis, collapse of 
the lungs, atrophy, measles, hooping-cough, or convulsions, but the pri- 
mary disease, which renders these secondary diseases fatal, is ignored." 

We shall limit ourselves to an account of the causes, general symptoms, 
and treatment of the disease, with a brief description of the anatomical 
changes in the bones, and the deformities which result, referring the 
reader who desires more minute knowledge on these latter points, to any 
of the elaborate memoirs published on this disease. 1 

1 Bibliography of Kickets — Shaw, Med.-Chir. Trans., vols, xvii and xxvi. 
Guerin, Mem. sur le Eachitis, Gaz. Med. de Paris, 1839, pp. 443, 449, 481. 
Elsasser, Der weiche Hinterkopf, Stuttgart, 1843. 
Meyer, Miiller's Arch., 1849, p. 358. 

Kokitansky, Path. Anat. (Syd. Soc), 1850, vol. iii, p. 174. 
Beylard, De Rachitis, &c. (These de Paris), 1852. 
Stiebel, in Virchow"s Path. u. Ther. Bd., i, p. 527. 

Vogel, Beitrage z. Lehre v. d. Rachitis, Erlangen, 1853; and Diseases of Children 
(Airier, ed., 1869), p. 520. 

Kolliker, Human Histology (Syd. Soc), 1853, vol. i, p. 352. 

Bouvier, Lect. Clin, des Malad. Chron. de l'Appar. Locom., 1856, p. 265. 

Mauthner, (Estr. Ztschr. f Kinderhlk., vol. ii, 11, 1857. 

Copland, Diet, of Pract. Med , 1858, vol. iii, p. 643. 

Priedleben, Beitr. z. Kenntniss wachs. u. rachit. Knochen, 1860. 

Jenner, Med. Times and Gaz., 1860. 



634 KICKETS. 

Causes. — Considerable difference of opinion exists upon the question 
whether rickets is hereditary or not ; but there seems no evidence to 
show that it ever is so, in the sense, for example, in which infantile syph- 
ilis is hereditary. There can, however, be no doubt as to the great in- 
fluence exercised by the health of the parents upon the development of 
the disease. 

It is stated by some authors that too early marriages, or marriages be- 
tween relations, and chronic tuberculosis or constitutional syphilis of the 
father, predispose to it. These causes are, however, of doubtful power ; 
and certainly are inoperative as compared with the very positive influence 
exercised by the condition of the mother. Thus, it is well ascertained, 
that whatever tends to induce debility and anaemia in the mother, as too 
irequent pregnancies, or prolonged lactation, renders it probable that her 
next born children will be rickety. Thus, Jenner states that it is very 
common for the first, or the two or three first born children, to be free 
Irom any sign of rickets, and yet for every subsequent child to be rickety ; 
which he explains b}^ the fact, " that among the poor the parents are gener- 
ally worse fed, worse clothed, and worse lodged, the larger the number of 
their children ; and among the rich and poor alike, the larger the number 
of children, the more has the mother's constitutional strength been taxed, 
and the more likely is she to have lost in general power." {Loc. cit.) 

In addition to the tendency derived from the mother, there are numer- 
ous causes acting directly upon the child, which strongly predispose to 
the disease. These will be found to be nearly the same as those which 
favor the development of tuberculosis. Thus, premature weaning, and the 
substitution of improper food for the mother's milk; or, on the other hand, 
the continuance of suckling long after the proper period for weaning, and 
after the mother's milk has deteriorated in quality and become insufficient 
and unwholesome ; or the use of indigestible, or of poor, scant} T , and in- 
nutritious food at any period during early childhood, are all potent causes 
of rickets. So too, many of the acute and chronic diseases of children, 
which impair assimilation and nutrition, as entero-colitis ; and all such 
depressing influences as impure water, foul air, poor ventilation, small, 
damp, and dirty habitations, may be classed among the predisposing 
causes. 

Symptoms. — It is highly doubtful whether rickets ever begins before 
the birth of the foetus. During the first four or five months of life also 
the disease is very rare, while in the great majority of cases it makes its 

Bouchut, Mai. des Enfants, 4eme ed., Paris, 1862, p. 825. 

G. Ritter von Kittershain, Die Path. u. Ther. der Rachitis, Berlin, 1863. 

Forster, Handb. d. Path. Anat., 2te Aufl., 1863, Bd. ii, p. 917. 

Virchow, Cellular Path. (Chance's trans., Amer. ed.), 1863, p. 476. 

Trousseau, Clin. Med., 2eme ed., 1865, t. iii, p. 453. 

West, Dis. of Children (4th Amer. ed.), 1866, p. 588. 

W. Aitken, Art. Rickets in Reynolds's Syst. of Med., 1868, vol. i, p. 768. 

Hillier, Dis. of Child. (Amer. ed.), 1868, p. 92. 

S. Gee, St. Barth. Hosp. Rep., vol. iv, 1868, p. 69. 

Niemeyer, Pract. Med. (Amer. ed.), 1869, vol. ii, p. 507. 



SYMPTOMS OF THE INITIATORY STAGE. 635 

appearance between the fifth month and the end of the second year, after 
which it becomes annually less and less frequent, and may be said to 
rarely arise after the close of the seventh year: 

The alterations and deformities of the bones, which are so character- 
istic of rickets, are not developed until after a more or less marked 
cachectic state of system has persisted for a time, varying from a few 
weeks to several months. 

During this initiatory stage, the most marked s3 T mptoms are connected 
with the digestive system. The appetite may remain good or grow ca- 
pricious ; and the bowels are irregular, though for the most part of the 
time there is diarrhoea, with stools which are at first greenish and mucous, 
subsequently serous, watery, of a brownish or slate color, and horribly 
offensive. If this chronic intestinal catarrh be but slightly marked, the 
child may retain a good deal of its fat, though frequently there is ex- 
treme emaciation. 

The next symptom which makes its appearance is general soreness and 
tenderness of the body, with pain on movement, so that the child dreads 
to be moved or even touched, cries if its limbs be pressed firmly, and 
will lie almost motionless for hours. 

The head is frequently bathed in profuse perspiration, which occurs 
especially during sleep, but also after any exertion or even while the 
child is lying quiet. The skin of the trunk and extremities is hot and 
dry, and even the lightest covering seems oppressive to the little pa- 
tient ; so that there is a tendency to get rid of all the bed-clothing at 
night. 

If the disease begins before the completion of primary dentition, 
the development of the teeth is always impeded, and they are not only 
cut late, but either decay or fall very early from their sockets. The 
urine does not present any constant alteration, but in a certain propor- 
tion of cases the amount is increased, and there is an excess of the phos- 
phatic salts, while in other instances excess of some free acid, said to be 
usually lactic, has been detected. The mental condition in rickets has 
been variously described ; some authors regarding the intelligence as pre- 
cocious, owing probably to the isolation of the patient from other chil- 
dren, and its constant association with its elders ; while others assert 
that there is an actual deficiency in intellectual capacity and power. At 
a somewhat later period of the disease the child acquires a peculiar staid 
and sedate aspect, which, when associated with the unusual breadth and 
squareness of the face, imparts a strange expression of age. 

According to Roger and Rilliet, a blowing murmur may frequently be 
heard over the anterior fontanelle in this disease, synchronous with the 
arterial pulse. As, however, this murmur is to be heard in other condi- 
tions, and is often absent in cases of rickets, it cannot be considered as 
a sign of any positive value. The causes which appear to intensif\ r it, 
are the ansemic state of the blood and the patency of the anterior fonta- 
nelle ; yet Hillier states that he has found it present in thirteen, and ab- 
sent in twenty-nine rickety children whose fontanelles were open. 

The phenomena above described, when present in the same case, may 



636 RICKETS. 

certainly be regarded as positively indicative of the existence of this 
initiatory stage of rickets, but they are b} T no means invariably all present, 
so that it is often impossible to determine the approach of the next stage 
in which the characteristic lesions and deformities of the bones make 
their appearance. 

Stage of Deformity. — After the initiatory stage has lasted for a vary- 
ing time, swellings begin to be noticed at the line of junction of the 
ribs and costal cartilages, and of the epiphyses and shafts of the long 
bones of the upper and lower extremities, giving in these latter places, 
as at the ankles and wrists, a peculiar knobby double-jointed appearance. 
With this, there is such a degree of softening of the bones, that they 
yield readily to pressure. 

If the disease reaches this stage before the child has begun to walk, 
there may be no deformity of the lower extremities whatever ; but in 
cases where the little patient has already been walking about, the femora 
bend so that thej^ become markedly convex forwards ; the tibiae bend in 
the same forward direction, while the knees may be bent inwards, thus 
giving to the legs a series of curvatures. The forward curvature of the 
femora ma} r indeed be produced before the child walks, simply by the 
weight of the legs and feet, which hang pendant from the knee-joints as 
the child sits in its mother's lap or on a chair. 

The bones of the upper extremities also share in these deformities ; 
thus the humeri bend at the point of insertion of the deltoids, from the 
weight of the arms when raised by the action of these muscles ; and both 
the humeri and the bones of the forearms become bent, from the pressure 
which the child makes on its open palms to assist itself in sitting up. 

The clavicles are very constantly deformed, and present a double cur- 
vature ; one curve being forwards and somewhat upwards, and seated just 
outside of the attachment of the sterno-cleido-mastoid muscle, the other 
being backwards, and seated about half an inch from the acromio-cla- 
vicular articulation. 

By far the most important deformities, however, are those presented 
by the head, spine, thorax, and pelvis. The peculiarities b}^ which the 
head in rickets is distinguished, are thus described by Jenner: 

1st. B} r the length of time the anterior fontanelle remains open. In 
the health}' child, it closes completely before the expiration of the second 
year. In the rickety child, it is often widely open at that period. 

2d. By thickening of the bones. This is usually most perceptible just 
outside the sutures, the situation of the sutures being indicated by deep 
furrows. 

3d. By the relative length of the antero-posterior diameter of the head. 

4th. B} T the height, squareness, and projection of the forehead. The 
first two of these peculiarities of the rickety head are the result of the 
affection of the bones ; the last two are due chiefly to disease of the cere- 
brum. 

Besides this thickening of the edges of the cranial bones, there are 
spots, irregularly distributed, where the bones are so thinned and soft that 
they yield to the pressure of the fingers ; and, indeed, in some cases the 



STAGE OF DEFORMITY. 637 

thinning is so extreme that the pericranium and dura mater come in con- 
tact. These ;i soft spots,'' first observed by Elsasser (loc.cit.), have been 
attributed to the pressure of the enlarging brain, but are more probably 
due merely to irregular deficiencj 7 of ossification. 

The curvature of the spine varies according as the child is able or 
unable to walk. In the latter case there is a posterior curvature of the 
spine, beginning at the first dorsal, and extending to the last lumbar 
vertebra ; while if the child is able to walk, this posterior curvature is 
limited to the dorsal region, but is combined with an anterior curvature 
in the lumbar region. The cervical anterior curve is increased, and con- 
sequent^ the face is directed upwards, and the head falls backwards, 
and being unsupported, owing to the muscular debility, sways loosely 
from side to side. Jenner points out that these curvatures may readily 
be distinguished from angular curvature, by the fact that the weight of 
the legs will usually remove them if the child be held by the upper part 
of the trunk, especially if the physician at the same time raises the lower 
limbs with one hand, and places the other on the curved spine. 

The thorax is subject to deformities, which in a practical sense exceed 
all others in importance, owing to the serious interference which they 
occasion with the action of the heart and lungs. 

In the first place, owing to the curvature of the spine, the ribs are 
flattened laterally, and run forwards more horizontally, so that the lateral 
diameter of the chest is greatly diminished, while the sternum is carried 
forwards, and thus the antero-posterior diameter of the thorax is in- 
creased. In addition, there is a marked groove on either side of the 
sternum, extending from the first to the ninth or tenth ribs, along the line 
of junction of the ribs with their cartilages. These grooves are produced 
by the bending of the ribs where the dorsal and lateral portions unite; 
from which point the} r pass forwards and inwards to unite with their 
cartilages, which curve outwards before uniting with the sternum. 

The curvatures and deformities which have been described before this, 
are chiefly due to the action of muscles or the weight of dependent parts ; 
but the production of the last-described deformities of the thorax is at- 
tributed by Jenner chiefly to the atmospheric pressure, which, during in- 
spiration, causes recession of the most yielding part of the thoracic walls, 
i. e., the softened ribs at the line of junction with their cartilages. In 
consequence of the support which the liver, heart, and spleen furnish to 
the ribs corresponding to their position, the groove extends further down 
on the left than on the right side ; but is deeper over the fifth and sixth 
ribs on the right than on the left side. 

The pelvis is frequently affected in rickets, and the deformities which 
result, on account of the great interference they cause in childbirth in 
the female, rank next in importance to those of the thorax. The rickety 
pelvis is characterized by a shortening of the antero-posterior diameter, 
so that the upper strait assumes an oval form, or is at times heart-shaped. 
In extreme instances the sides also approximate, and give to the pelvis a 
triangular shape. It is evident that the form will be influenced by a num- 
ber of conditions ; as the stage of ossification, and the direction in which 



638 RICKETS. 

the pelvis is compressed by the spine from above, and the thigh bones 
from below. 

Partly in consequence of the diminished capacity of the thorax and 
pelvis, partly in consequence of the weakness of the abdominal muscles, 
the flatulent distension of the intestines, and the enlargement of the liver 
and spleen which are frequently present, the abdomen is unusually prom- 
inent in rickety children. 

During the development of the alterations in the bones, the general symp- 
toms before described persist ; the digestion is enfeebled, and the stools 
liquid and fetid; the emaciation and debility increase; the respiration is 
more or less embarrassed by the deformities of the thorax ; the pulse is 
quick, small, and irritable ; the skin hot, excepting on the head and neck, 
where it is still frequently bathed in sweat; and the general tenderness 
of the body is aggravated. 

In cases where the disease approaches a favorable termination, the 
earliest signs of improvement consist in a decrease in the emaciation, 
debility, and suffering ; the stools become more healthy, and the febrile 
symptoms, if any have been present, disappear. 

During this stage of early convalescence, when the children attempt to 
leave the bed and walk about, holding on to the chairs, there is great 
danger of increased curvature and even of partial fractures of the bones of 
the lower extremities. 

When, on the other hand, death occurs during the course of rickets, it 
is rarely from the intensity of the cachexia (which explains the apparent 
anomaly of so fatal a disease being scarcely represented in the mortality 
returns), but from the supervention of some secondary disease. Among 
these, the following are enumerated b} r Jenner as the most frequent causes 
of death: 

1. Catarrh and bronchitis, which are rendered far more dangerous from 
the mechanical interference with respiration caused by the deformed 
thorax. 

2. Albuminoid infiltration of various organs, especially of the spleen 
and lymphatic glands. This peculiar form of degeneration is not un- 
frequently developed during the course of rickets ; it manifests itself by 
increased emaciation, extreme pallor, occasional oedema and albuminuria, 
and enlargement of the affected organs. 

3. Laryngismus stridulus, which, according to Jenner, is essentially 
connected rather with the nervous irritability due to rickets, than with 
the tardy and difficult dentition which is itself but another expression 
of the constitutional disease. 

4. Chronic hydrocephalus. 

5. Convulsions, depending like the laiyngismus stridulus, upon the 
heightened irritability of the nervous system. 

6. Persistent and severe diarrhoea, which is probably due in many cases 
to albuminoid degeneration of the intestinal mucous membrane. 

Duration ; Prognosis. — The duration of rickets varies so greatly, 
that the disease may be said to present an acute and chronic form. 
When the diathesis is marked, the hygienic conditions of the child 






DIAGNOSIS — MORBID ANATOMY. 639 

very unfavorable, and the disease makes its appearance at an early age, 
its course is often very rapid, and death usually follows. When, on the 
other hand, the disease does not begin till late in the second or third 
year, and when the surroundings of the child are more favorable, recovery 
usually occurs, although the disease ma}^ last for several years. 

An unfavorable prognosis may be made, then, when the disease begins 
in very early infancy ; when it is attended with marked constitutional dis- 
turbances ; when the deformities of the head and thorax are rapidly and 
extremely developed ; when any of the secondary morbid conditions above 
enumerated have supervened. When, on the other hand, the reverse of 
these conditions obtains, recovery may be expected, though often only 
after prolonged illness. 

Diagnosis. — It is only during the initiatory stage of rickets, that the 
true nature of the attack is likely to be mistaken. But during this stage 
the disease may be confounded either with chronic entero-colitis, or with 
tuberculosis of the peritoneum and intestinal canal. Careful attention. 
to the peculiar symptoms of rickets, especially the sweating of the head, 
the general soreness and tenderness of the body, and the retardation of 
dentition, will, however, lead to a correct diagnosis, even before the 
swelling of the sternal ends of the ribs and of the epiphysial lines of the 
long bones, and the projection of the sternum, remove all doubt as to the 
nature of the case. 

Morbid Anatomy. — The essential lesions in rickets consist of the changes 
in the bones, though there are also certain lesions of the viscera which 
are frequently met with. 

The bones affected by rickets in addition to the deformities already 
described, are clumsy, and present marked swellings at the line of their 
junction with the epiplryses. This enlargement is due to excessive de- 
velopment of the spongy tissue in the extremity of the bone and the epi- 
physis, and to marked proliferation of the epiphysial cartilage. The fact 
that the epiphyses widen instead of elongating, is due to the pressure of 
the superimposed parts upon the soft proliferating layers, causing them 
to bulge laterally. 

The deposition of calcareous granular particles at the line of ossifica- 
tion is also wanting, and the cartilage cells calcify before the matrix be- 
gins to ossify, and are converted into bone cells. 

There is thus excessive formation of the structures which precede or 
form the nidus for ossification, while there is at the same time retardation 
or incomplete performance of that process. 

At the same time, the diaphyses present rarefaction of their tissue, 
not owing to undue softening and removal of old bone, but simply to the 
fact that, while the old layers of bone are consumed by the normally pro- 
gressive formation of medullary cavities, the new layers which are pro- 
duced are soft and do not ossify. 

The medullary space may reach the line of ossification, or even project 
beyond it into the proliferating epiphysial cartilage. 

The periosteum of rickety bones is usually thickened and highly vas- 
cular. 



640 RICKETS. 

The bones themselves become so soft that they may be bent in any di- 
rection, or even cut with a knife without difficult}^ 

Upon section the spongy tissue and the enlarged areolae are found 
filled with a crimson pulp, containing blood-globules, a large amount of 
free fat in some cases, and very many round, faiutly granular cells, with 
one or two nuclei. 

The softening of the bones is fully accounted for by the diminution in 
the proportion of their calcareous salts. Thus Jenner states as the mean of 
the anal}- ses of several observers, that the bones of healthy children yield 
about thirty-seven parts of organic and sixty-three of inorganic matters ; 
whereas those of rickety children yield about seventy-nine parts of or- 
ganic to twenty-one parts of inorganic matters. In addition to this, it 
would appear that the organic matters themselves undergo change, since 
it has been found by several experimenters that the bones in advanced 
rickets yield neither chondrin nor gelatin on boiling. 

The thickening of the flat bones is caused by the formation of new 
osseous layers from the thickened and vascular periosteum, which are 
formed at or near the growing margins of the bones, thus accounting for 
the thickened ridges near the sutures of the cranial bones. 

In addition to these changes in the bones, which are the constant and 
essential lesions in rickets, there are certain lesions of the viscera fre- 
quently met with, which depend partly upon the deformities of the skele- 
ton and partly upon the general cachexia. Thus, in consequence of the 
peculiar deformity of the thorax, the anterior borders of the lungs become 
highly emphysematous, while the band of lung-tissue corresponding to 
the deep groove at the sternal end of the ribs is compressed and col- 
lapsed. 

This peculiar and constantly present strip of collapsed lung, is due to 
the recession of the corresponding part of the ribs during inspiration ; 
but frequently there is also found extensive collapse of the postero-infe- 
rior parts of the lungs from the ordinary causes, bronchitis and impeded 
respiration. Jenner has also called attention to the frequent presence in 
rickets of white spots upon the pericardium, near the apex of the heart. 
These spots thus correspond to the depressed part of the fifth left rib, 
and are in all probability due to the friction of the heart against this hard 
knuckle of bone. 

In some cases, as already said, the organs, as the liver, spleen, kidneys, 
lymphatic glands, gastro-intestinal mucous membrane, &c, become the 
seat of albuminoid (amyloid of Yirchow) degeneration. They are en- 
larged, firm, with a peculiar doughy elasticity, and often bear the impress 
of contiguous viscera: upon section but little blood escapes, and the cut 
surface is pale, compact, and homogeneous, with a peculiar waxy, trans- 
lucent appearance. Jenner regards this change as different from that 
described by Yirchow under the name "amyloid degeneration," because 
he has failed to obtain from such organs either a blue, violet, or crimson 
reaction, with iodine and sulphuric acid. Dr. W. H. Dickinson, in a paper 
recently read before the Medico-Chirurgical Society of London, also states 
that the enlarged viscera in cases of rickets give no reaction with iodine. 



PATHOLOGY — TREATMENT. 641 

He describes the change which the} 7 present as cine, not to the presence 
of any formation foreign to their structure, but to an irregular hypertro- 
phy which alters the natural proportion of their tissues ; and as differing, 
pathologically and clinically, both from the amyloid change and from the 
enlargement of the spleen and lymphatic glands known as Hodgkin's 
disease. 

In cases where death is directly due to any secondary disease, as bron- 
chitis, intestinal catarrh, or chronic hydrocephalus, there will of course 
be found in addition the lesions common to such affections. 

Pathology. — The description which has been given of the symptoms 
of rickets, clearly establishes the fact that it is a constitutional disease, in 
the same sense that scrofula and tuberculosis are; and we are conse- 
quently to regard the lesions of the bones as merely a local manifestation 
of the general cachexia. We are unable, however, to advance beyond this 
point, since we are ignorant, not only of the essential nature of the vice of 
nutrition, but equally so of the specific nature of the changes in the bones. 
The result of chemical analysis has led to the theory that the disease 
essentially consists in a deficiency of the calcareous salts of the bones ; 
and the attempt has been made to explain this deficiency by supposing 
an excess of lactic acid in the primse vise and blood, which holds the cal- 
careous salts in solution, and prevents them from being deposited in the 
bones. Apart from the purely lrypothetical nature of this supposition, 
and its entire inadequac}- to explain many of the most serious symptoms 
of rickets, it is to be borne in mind that the excess of free acid in the 
urine is far from being constant, and that the changes in the bones are 
characterized not merely by a deficient deposit of the calcareous salts, 
but by their abnormal position, and by all the evidences of an active vital 
process. 

Again, the marked vascularity of the bone and periosteum, the rapid 
proliferation of cells, and the pain and constitutional irritation which 
attend the disease, have induced others to regard the process as an in- 
flammatory one. But this view is controverted as well by the etiology 
and clinical history of the disease as by its constant anatomical results. 

Treatment. — In cases where there is reason to anticipate the develop- 
ment of rickets, as where the previous children of the mother have be- 
come rickety, the utmost attention must be paid to the feeding and 
hygiene of the young infant. If careful examination of the mother's 
milk proves that it is unsuitable in quality, a wet-nurse should be imme- 
diately provided, or, if that be unattainable, the child should be fed upon 
carefully selected cow's milk, or upon one of the substitutes for human 
milk described in the article on thrush. 

So too, after the disease has made its appearance, the most appro- 
priate, nutritious, and digestible diet must be selected, care being taken 
that it shall contain a large proportion of animal food. 

The teeth of rickety children are so defective that, when they begin to 
take solid food, it is highly necessary to insure its complete mastication, 
and in cases where the condition of the teeth renders this impossible, the 
meat should be chopped finely and bruised in a mortar. 

41 



642 RICKETS. 

The childsbould.be suitably and warmly dressed, and be taken freely 
into the sunlight and open air. The use of salt water baths, followed by 
active friction of the skin, is also to be recommended. 

During the early stage, when there is marked constitutional irritation 
and pain, the remedies used to relieve these symptoms should be alkaline 
mixtures, such as the effervescing draught or neutral mixture, or magnesia 
(Copland), conjoined with sedatives and tonics. Under no circumstances 
should any depressing plan of treatment be adopted. 

If the digestion be much impaired and diarrhoea is present, the use of 
vegetable tonics, or wine of iron, with mild astringents and antacids, is 
indicated. 

The remedy, however, from which most benefit is usually derived is 
cod-liver oil. and it should consequently be given, in conjunction with 
iron and A'egetable tonics and a small amount of some generous wine, as 
soon as the nature of the attack is recognized and persevered with for 
months, or until the disease is overcome. 

The efficacy of cod-liver oil in the treatment of this disease is, indeed, 
so remarkable that all other remedies formerly used have been supplanted 
by it. Yogel asserts (op. cit., p. 534) that, " Rachitis ma}' be cared by the 
use of cod-liver oil alone, even if the circumstances are in other respects 
unfavorable." Rickety children usually tolerate the oil well, and even 
become so fond of it that they will willingly take large doses. In some 
cases, however, it disagrees with the stomach and is obstinately refused 
by the children ; and when this happens, so important is the introduction 
of the oil into the system, that we should recommend its use by inunction. 

There can be no doubt that when rickets is recognized in its early 
stages, and a suitable medicinal and hygienic treatment prompt!}' insti- 
tuted, it is usually curable in a comparatively short time. When, how- 
ever, the diathesis is strong and the case overlooked until softening of the 
bones has occurred, and deformities begin to appear, the treatment must 
be persisted in for many months or even years. In such cases, unfor- 
tunately, there is only too great probability of the deformities increasing 
and becoming permanent, even if death does not ensue from some inter- 
current or superinduced disease. 

In order to guard against deformities, the little patient should lie upon 
a firm, smooth mattress, and high pillows should be forbidden. Memeyer 
recommends that small children should be carried out in a basket ; while 
larger ones should be drawn about in a carriage provided with a mattress. 
Sitting up for any length of time, or attempts at walking, should be pro- 
hibited until the bones have grown firm and inflexible. 

It is not advisable, especially during the earlier stages of the disease, to 
employ any mechanical contrivances to prevent or relieve deformities. 
During convalescence, however, attempts may be made to control the 
deformities by means of leather or pasteboard splints. 

In the treatment of any intercurrent affections it must be remembered 
that we have to do with a condition of malnutrition and enfeebled vitality, 
so that all remedies of a depressing character must be scrupulously 
avoided. 



CAUSES — ANATOMICAL APPEARANCES. 643 

AKTICLE V. 

TUBERCULOSIS. 

This subject has received from mairy authors upon diseases of children, 
far less attention than it merits, under the idea that it is merely a repe- 
tition, upon a small scale, of the same disease in the adult, and not pos- 
sessed of any individual characteristics. In fact, however, tuberculosis 
in childhood is an affection possessing characters and presenting symp- 
toms entirely special, and differing from its manifestation in adult life 
both in causes, locality, and clinical history. 

Causes. — The causes which exert most manifest influence in its pro- 
duction are hereditary tendency, and all those debilitating agencies which 
act directly or indirectly upon nutrition. Of these latter causes, early 
weaning is the most prominent. Thus, we have met with a case where a 
healthy woman, the mother of several vigorous children, all of whom she 
had nursed, gave birth to one which she was unable to suckle, and this 
child, after pining for some months, died of an attack of tubercular men- 
ingitis. A bad quality of the nurse's milk, or improper artificial food 
after weaning, also exert a powerful influence in the production of tuber- 
culosis ; and not unfrequentfy its development has been traced to repeated 
attacks of indigestion or diarrhoea. 

It has also a tendency to develop itself after certain acute affections, 
especially in children predisposed b}^ hereditary influence. Of these dis- 
eases, rubeola, pertussis, typhoid fever, and, according to Greenhow, 
variola, are most frequently followed by tuberculosis. 

There is still some difference of opinion in regard to the role which 
pneumonia plays in the development of tuberculosis. When the two co- 
exist, the inflammation is by some regarded as a secondary affection, in- 
duced by the deposit of tubercle in the lung; while by others it is held 
that, amongst predisposed children, it is the pneumonia which causes the 
development of tuberculosis of the lung. We believe that pneumonia oc- 
cupies each of these relations in a certain number of cases ; but reliable 
statistics upon this point are still too scanty to determine the exact pro- 
portion. 

Anatomical Appearances. — The most frequent seats of tubercular 
deposit in the child are the brain, constituting tubercular meningitis, 
which has already been treated of at length ; the bronchial glands, the 
lungs, and the mesenteric glands and peritoneum. It is, however, one of 
the distinguishing features of tuberculosis in the young subject, that it is 
apt to involve several viscera simultaneously, while not unfrequentby the 
lungs remain free. Thus, in 312 children in whom Killiet and Barthez 
found a deposit of tubercle in one or more of the viscera, the lungs were 
healthy in 4*7 ; while in 123 similar instances in the adult, Louis only 
found one such exception. 

Locality. — In bronchial phthisis, which generally accompanies pul- 
monary phthisis, but also exists as a separate affection (though, ac- 



644 TUBERCULOSIS. 

cording to Bouchut, this is a rare occurrence), the glands are much en- 
larged and enclose tubercular matter, frequently in large proportion. 
This is especially marked in those glands which lie along the trachea 
and around its bifurcation, and, when many of them are involved 
and adherent to each other, they form masses varying in size from a 
hen's egg to a large apple. The deposit, which in by far the majority of 
cases exists as infiltrated tubercle, does not usually soften, though cases 
are recorded where such softening has occurred, and the fluid has been 
discharged through an opening into a bronchus. Obsolescence and cal- 
cification, however, are quite common terminations of bronchial tubercles; 
and when the lungs dt> not become involved in the morbid process, a cure 
may be effected by these transformations. Calcified tubercle may be elimi- 
nated through a communication between the gland and one of the air- 
passages ; and a few cases are also reported where the oesophagus, tra- 
chea, and even the pulmonary arteiy have been perforated in this manner. 
Most of these tuberculous glands are enclosed in a distinct and dense 
•capsule, which may attain the thickness of one or two lines, and is usu- 
ally quite vascular. This fibrous capsule is due to the hypertrophy of 
the originally delicate cellular investment of the gland. 

Pulmonary Phthisis. — The anatomical characters of tubercle of the 
lungs in children, present several peculiarities, as distinguished from the 
same deposit in adults. Thus gray granulations and crude miliary tuber- 
cles frequently exist in the lungs, independently of each other and of any 
other form of tubercular deposit. In the adult, Louis discovered miliary 
tubercles unassociated with gray granulations only in 2 out of 123 cases, 
or in 1.6 per cent.; and gray granulations alone in but 5 more, or 4 per 
cent. ; while in the child, Rilliet and Barthez found miliary tubercles with- 
out gray granulations in 10T out of 2.65 cases, or in 40.4 per cent.; and 
graj T granulations alone in 36 instances, or in 13 per cent. ; and the ob- 
servations of West, "which are based on 102 cases, jield 20 instances of 
the presence of miliary tubercles alone, and IT of the presence of gray 
granulations alone in the tissue of the lungs." 

The great frequency with which the so-called yellow infiltrated tubercle 
is observed in early life constitutes another anatomical peculiarhVy, Rilliet 
and Barthez, and West having found it in from 23 to 33 per cent, of their 
cases. This condition rarely exists as an isolated state, but is found in 
conjunction with gray granulations and crude yellow tubercles, and not 
unfrequently also with advanced tuberculization of the bronchial glands. 

The rare occurrence of cavities in the lungs is a most striking peculi- 
arity of phthisis in children. It is probably no exaggeration to say that, 
in adults, cavities are found in the lungs in 90 out of every 100 cases of 
tuberculosis ; whilst out of 265 cases of tuberculosis of the lungs in children 
that came under the notice of Rilliet and Barthez, only TT, or 29 per cent., 
presented cavities ; they existed in only 23.5 per cent, of West's cases, 
and Bouchut found them in but 3 out of 36 cases. 

Occasionally the cavities resemble the vomicae found in the lungs of 
adults, and this occurs with more frequency as we advance beyond the 
age of six years. In other cases the excavation is produced by the soft- 



ANATOMICAL APPEARANCES. 645 

ening of very small tuberculous deposits, distinct, though in close prox- 
imity, which forms small vacuoles, communicating with each other and 
with the neighboring bronchial tubes. All three of M. Bouchut's cases 
appear to have been of this form. 

In addition to these two varieties of tuberculous cavities, there is still 
a third, produced by the simultaneous softening of considerable portions 
of a lung affected with yellow infiltration. This action, which is most 
commonly met with in very early life, and in cases which progress with 
great rapidity, pervades the whole of the tissue affected, instead of pro- 
ducing a central cavity. Cavities of this kind sometimes form very 
quickly, and involve large portions of lung, the whole of one lobe even 
being converted into a mere sac, with thin walls. 

There is another form of excavation occasionally noticed, which is not 
a true pulmonary vomica, but the result of the softening and evacuation 
of a tuberculous pulmonary gland. The diagnosis, however, may be 
rendered easy by reflecting that a pulmonary cavity of such small dimen- 
sions is hardly ever solitary, unless it proceeds from the softening of 
tubercular infiltration, whilst the deposit of tubercle which takes place in 
the neighborhood of a diseased pulmonary gland is always in the form 
of distinct deposits, not of tubercular infiltration (West). 

The last anatomical peculiarity, already alluded to, of pulmonary 
phthisis in children, is its frequent complication with tubercular deposit 
in the bronchial glands. 

Peritoneum. — Tubercular deposit on the peritoneum rarely or never 
occurs without the presence of a similar disease in some other parts of 
the economy. It may be either general or partial in its disposition, 
though it is far more frequently the latter. The deposit varies also in 
its character, appearing generally in the form of yellow granulations or 
of miliary tubercles, either isolated or united into small masses. Gray 
granulations, however, are also of quite frequent occurrence. 

The relation wmich the tubercles bear to the peritoneum is not uniform, 
though they are more frequently found deposited on its surface than be- 
neath it. In 86 cases examined by Rilliet and Barthez, the seat was as 
follows : intra-peritoneal in 40 ; extra-peritoneal in 22 ; both intra- and 
extra-peritoneal in 14 ; in the other 10 cases the exact seat was doubtful. 

When the deposit involves the entire extent of the serous membrane, 
we find the anterior parietes of the abdomen adherent to the subjacent 
structures, and the viscera so matted together and adherent, as to form 
an almost inseparable mass. More frequently, however, the tuberculiza- 
tion is partial, and even limited to the vicinity of a single organ. The 
peritoneum investing the diaphragm, especially that portion which is in 
contact with the liver or spleen, or the adjacent parietal peritoneum, is 
very often affected ; and as tubercles rarely fail to be deposited in the 
peritoneum covering these A^scera, we find them firmly adhering to the 
diaphragm or abdominal wall. 

In some cases the omentum is the chief seat of the disease, and may 
either present numerous gra} T granulations scattered through its folds, 
or may be thickened or matted together from a kind of grayish tubercular 



646 TUBERCULOSIS. 

infiltration, due to the coalescence of innumerable minute gray granula- 
tions. It is more rare to find the tuberculization limited to the intestines, 
merely causing adhesion of the adjoining coils. 

In examining the adhesions which are almost universally found to exist 
between the various organs and portions of peritoneum affected, we find 
them to present two elements. In the first place, the tubercular deposits 
on the adjoining surfaces gradually coalesce as they increase in size, and 
finally unite the surfaces by more or less extensive patches of tubercular 
matter. And again, at the same time, the subacute inflammation caused 
hy their presence leads to the formation of cellular and fibrous adhesions 
as in cases of simple peritonitis. This is well seen in cases where some 
coils of the intestine present tubercular adhesions to each other, forming 
masses which can only be separated by rupturing the walls of the bowel, 
while between other coils the adhesions merely consist of delicate and 
easily lacerated cellular bands. 

It is a well-established fact that the tubercular granulations on the sur- 
face of the peritoneum have no tendenc} T to perforate this membrane ; but 
that the perforations which are occasionally found, especially in the walls 
of the intestines, are due to the development and softening of the sub- 
peritoneal tubercles, which always tend to penetrate into its cavhry. This 
same law holds elsewhere, and it is on this account that the adhesions 
which so constantly form between tuberculous membranes are of such 
great value in preventing the escape of foreign matters into the serous 
cavities. In the intestines this action can be traced even further, and 
when tubercles exist under both toers of the peritoneum at a point of 
adhesion between two folds of intestine, as softening advances, the hirers 
of peritoneum are destroyed, and the little collection of tuberculous pus 
remains confined only by the inner coats of the two ^ers of bowel. 
Sooner or later these also break down, the softened tubercle is discharged 
into the bowel, and a direct communication established between distant 
parts of the intestinal canal, as between a fold of the ileum and the as- 
cending or descending colon. This perforation, then, is not caused by 
tuberculous ulceration of the mucous membrane ; nor does this latter affec- 
tion bear any fixed relation to the degree of tuberculization of the peri- 
toneum. 

There is generally some deposit of tubercle in the mesenteric glands in 
these cases ; and when the splenic portion of the peritoneum is involved, 
we frequently find an abundant deposit in this organ. 

Tuberculization of the mesenteric glands, or tabes mesenterica, offers 
few anatomical features in addition to those present in bronchial phthisis. 
It is, moreover, far from being a frequent form of the disease, for, although, 
according to Rilliet and Barthez, some tubercle is found in these glands in 
one-half of all tuberculous subjects, it exists in considerable quantity only 
in one out of every sixteen of the whole number. The deposit generally 
appears as infiltrated tubercle, though not unfrequently miliary tubercles 
are present. The glands attain a size varying from that of an almond to 
a pigeon's egg, and occasion all} T , from the aggregation of several enlarged 
glands, a mass is formed double the size of the child's fist. 



ESSENTIAL NATURE — SYMPTOMS. 647 

The capsule which surrounds them is usually more delicate and less 
vascular than the same structure in tuberculous bronchial glands. The 
tubercular deposit here, as elsewhere, is liable to undergo calcification or 
softening, the latter process being more frequently met with. 

Owing both to the yielding nature of the abdominal walls, which do not 
resist the forward growth of the mesenteric glands, and to the mobility 
of the adjacent viscera, we never see the same degree of compression 
exerted on surrounding structures, as is noticed in tuberculization of the 
bronchial glands. 

Occasionally, however, adhesions may form between a tuberculous 
mesenteric gland and a fold of the intestine, and ultimately result in per- 
foration of the bowel. 

In thus describing these various lesions as being all tuberculous in 
their essential nature, we have purposely employed this term in the some- 
what inaccurate and vague sense which was assigned to it until within 
the past few years. 

Recognizing, as we distinctly do, but one elementary form of tubercu- 
lous deposit, the gray granulation or miliary tubercle, which may, it is 
true, undergo cheesy degeneration, it is evident that many of the cases 
in which extensive and uniform cheesy deposits are found, rather depend 
upon scrofulous inflammation of the part thaii upon true tuberculous 
formation. It is comparatively rare to meet with such cheesy deposits in the 
lungs in children, while, as already described, they occur very frequently 
both in the bronchial and mesenteric glands. And, therefore, we are dis- 
posed to believe that in many cases of so-called bronchial or mesenteric 
phthisis, the enlargement and degeneration of the glands is really clue to 
an inflammatory process of a low and unhealthy type, excited by the pre- 
vious occurrence of attacks of bronchitis or enteritis, and leading to the 
formation of a cacoplastic lymph which soon undergoes cheesy degen- 
eration. 

It is in this waj T , doubtless, that the comparatively numerous cases are 
to be explained in which such deposits soften and are evacuated, or un- 
dergo partial absorption and calcification, and where ultimately the child's 
health is restored. We have preferred, however, in the present edition, 
for practical purposes, to group the descriptions of these various condi- 
tions under one common head, being unwilling to separate them until 
more extended study shall have more clearly demonstrated the degree of 
resemblance which exists between true tuberculous matter and such caco- 
plastic inflammatory formations. 

Symptoms. — The sj^mptoms of tuberculosis in children may be studied 
under the forms of bronchial phthisis ; acute and chronic pulmonary 
phthisis ; and tuberculization of the peritoneum and mesenteric glands. 

Bronchial Phthisis. — In addition to the general symptoms of tubercu- 
losis, which will be fully given under the head of pulmonary phthisis, the 
most marked symptoms of bronchial phthisis are those due to the me- 
chanical effect of the enlarged and hardened glands upon the surround- 
ing tissues. Our knowledge of the functions of the lymphatic glands is 
as yet so inaccurate that we are entirely unable to appreciate the symp- 



648 TUBERCULOSIS. 

toms of disordered action which are probably present in cases of exten- 
sive disease of these organs. 

Bronchial phthisis occurs in its best marked form between the ages of 
two and six years ; and in many cases appears to be developed after some 
severe attack of bronchitis, either accompanying measles or arising with- 
out apparent cause. 

The cough which, in the early stage, is hacking and not very trouble- 
some, soon acquires severity and becomes intermittent, recurring in par- 
oxysms like those of pertussis. 

The respiration becomes habitually labored and oppressed, with a pro- 
longed wheezing sound, as in asthmatic cases. 

The veins of the neck are often greatly distended, the distension be- 
coming extreme during the violent parox3 T sms of coughing ; the face 
becomes puffy and cedematous, a condition occasionally extending to the 
upper extremities ; and, as West points out, the superficial vessels of the 
thorax become enlarged, just as those of the abdomen do in cases of 
cirrhosis of the liver. The obstruction to the return of blood from the 
superior vena cava is further shown by the occurrence of epistaxis, or 
even of hemorrhage into the arachnoid ; and the compression of the pul- 
monary tissue occasionally produces haemoptysis and oedema of the lungs. 
Dr. Jenner has seen hydrothorax produced from compression of the vena 
azygos. 

The oesophagus does not always escape the encroachment of the glands, 
but ma}' be so compressed as to produce dj~sphagia. 

It is hardly necessary to say that so long as the tubercular deposit re- 
mains small, it may exist without causing any s3'mptoms, and it is only 
when several glands become stuffed with tubercle, enlarged and firm, that 
they give rise either to the symptoms already enumerated, or to the phys- 
ical signs below alluded to. 

Physical Signs. — In estimating the value of these, it is necessary to 
constantly bear in mind the fact that the enlarged and tuberculous bron- 
chial glands, while they still surround the trachea and bronchi, also come 
into contact with the spinal column, or in a few cases, with the sternum. 
From their solidity, and the consequent readiness with which they are 
thrown into vibration, they transmit directly to the ear and seem to ex- 
aggerate many respiratory sounds, which are in reality produced at a 
distance from the thoracic walls, and which are either entirety normal or 
dependent upon a small amount of disease. 

It is also due to these relations, that the signs, both of auscultation 
and percussion, of bronchial phthisis are best detected at the summit of 
the lungs posteriorly, or at the level of the vertebrae with which the en- 
larged glands come in contact. 

Our knowledge of these important considerations is chiefly due to the 
investigations of Eilliet and Barthez. 

Percussion. — In the young child in health, there is a diminution in 
resonance over the manubrium of the sternum, owing to the remains of 
the thymus gland ; but, in some cases of marked bronchial phthisis, this 
dulness extends both downwards and laterally to a varying, but percepti- 



PHYSICAL SIGNS OF BRONCHIAL PHTHISIS. 649 

We degree, owing to the projection of the enlarged glands into the an- 
terior mediastinum. 

More generally, however, as we have said, the tuberculous glands are 
in contact with the spinal column, so that we find dulness on percussion 
in the interscapular space as a pretty constant and characteristic symptom. 

According to Dr. Jenner, it is common to have a cracked-pot sound on 
percussing the cartilages of the upper three ribs on one or both sides. 
This is due to the fact that the enlarged glands accompanying the bron- 
chial tubes frequently extend under the anterior margin of the lungs, so 
that, in percussing, the air-containing lung is compressed between the 
solid mass of glands behind and the in-driven parietes in front, and the 
air is forced out suddenly from the healthy layer of lung, producing 
the chinking sound. 

Auscultation often reveals true tubular breathing over the upper part 
of the sternum, extending almost to the base of the heart. In those cases 
where a large bronchial tube is compressed or occluded, we of course 
find an enfeebled or extinct respiratory murmur over the corresponding 
lung segment. 

Occasionally the enlarged glands compress the superior vena cava, and 
give rise to a permanent venous hum ; or a systolic murmur, having its 
seat of greatest intenshyv at the second left interspace, ma}' be produced 
by similar compression of the pulmonary artery. 

There is one characteristic, however, of this form of phthisis, which is 
especially dwelt upon by Dr. West, and which it is well to bear in mind, 
to avoid being misled. This is the frequent occurrence of great fluctua- 
tions in the condition of the patient ; so that, even when the rapid breath- 
ing, frequent cough, emaciation and loss of strength would betoken a 
speedily fatal issue, a pause will occur in the progress of the disease, 
during which the diminution of any bronchitic complication, with partial dis- 
appearance of the dyspnoea and cough, and the return of flesh and strength 
to the little patient, all tend to awaken delusive hopes. In the great ma- 
jority of cases, this respite is but brief, and the disease again resumes its 
onward course ; but there are well-authenticated cases on record in which 
the gravest sj^mptoms have gradually disappeared, and the child has ulti- 
mately regained fair health. In these. cases, the tuberculous deposit may 
either have undergone cretaceous degeneration, or, having softened and 
formed an opening into a bronchus, have been expectorated. 

The characteristics of bronchial phthisis, which we have been consider- 
ing, are thus summed up by West : 

" 1. The frequent development of its symptoms out of one or more at- 
tacks of bronchitis. 

" 2. The peculiar paroxysmal cough which attends it, resembling that 
of incipient pertussis. 

" 3. The great and frequent fluctuations in the patient's condition, and 
the occasional and apparently causeless aggravation both of the cough 
and dyspnoea." 

Symptoms of Pulmonary Phthisis. — Valuable as are the general symp- 
toms of tuberculosis in the adult, it is in the young child peculiarly that 



650 TUBERCULOSIS. 

the} T reach their highest importance, owing either to the absence or the 
difficulty of appreciation of man}' symptoms which aid greatly in the 
diagnosis of phthisis in adult life. 

It is necessaiy, therefore, to examine with the greatest care the child's 
hereditary tendencies, its past history, and its appearance and physical 
development. Thus it is in cases of inherited tuberculosis that we see 
its characteristic features most strongly marked, in the tall, slim frame ; 
the firm bones, with small and yielding cartilages ; the delicate diapha- 
nous complexion ; the fine, silky hair ; the active, often precocious intel- 
ligence ; the ease with which the general health is affected by slight 
causes, and the peculiar proneness to catch cold on the least exposure. 
By careful attention to these and other similar points, as much, or often 
more, valuable information can be obtained in the phthisis of children, 
than from the most careful investigation of the plrysical signs. 

In enumerating the symptoms, it is unnecessary to detail those which 
exist in common with pulmonary phthisis in the adult, save to point out 
an}' particular in which they m&y differ as seen in the young subject. 

The cough varies much in accordance with the varying amount of bron- 
chial irritation, being at one time scarcely troublesome, or so aggravated 
and accompanied with such violent dyspnoea, from some intercurrent at- 
tack of bronchitis, as to threaten immediate death. 

It not unfrequently has a somewhat paroxysmal character, from the 
accompanying tuberculization of the bronchial glands. One of the most 
marked peculiarities of the cough in the phthisis of children is the entire 
absence of expectoration, since the secretions are either retained in the 
bronchial tubes, or, if raised into the pharynx, are swallowed without any 
effort at expulsion. 

Haemoptysis very rarely occurs in the early stage or during the progress 
of the disease ; and when it occurs as the cause of sudden death, is due 
to .the complication with bronchial phthisis, rather than to the rupture of 
a bloodvessel in a pulmonary vomica. 

The temperature of the body is, as a rule, higher than normal, although 
it presents fluctuations on different days, and even at different hours of the 
same cla3 T ; at times being normal, and again rising as high as 102°, or 
more. The greatest elevation of the temperature is generally noticed at 
night, and is usually accompanied by flushing of one or both cheeks ; but 
it is rare to find the colliquative night-sweats which prove so exhausting 
to adults. 

The pulse is always accelerated, and becomes very frequent as the tem- 
perature rises. 

The appetite is capricious, the tongue furred, and the digestion imper- 
fect ; the bowels alternate from a state of constipation to diarrhoea, and 
the stools are unhealthy in appearance, being generally putty-like or 
clay-colored. Naturally, with this disturbed state of the primae via?, nu- 
trition is seriously impaired, and the child steadily loses flesh and strength. 
Indeed, in very many cases, the little patient presents merely the symp- 
toms of impaired nutrition, becomes languid and drooping, and loses 






PHYSICAL SIGNS OF PULMONARY PHTHISIS. 651 

appetite, strength, and flesh, for man} 7 weeks before the development of 
cough reveals the lungs as the seat of the disease. 

Phutieal Sign*. — We have already remarked the fact that in the inves- 
tigation of phthisis, the physical signs are of much less value in the case 
of children than in adults. This arises not only from peculiarities of the 
physical and moral organization in childhood, but also from the mode in 
which the tuberculous deposit takes place. Thus, as a rule, the deposit 
of tnberele in the lungs of children is more generally diffused and uni- 
form ; so that we lose to a great degree the advantages derived in adults 
from a comparison of the results of auscultation and percussion in one 
part, with those obtained in another. For the same reason, we are also 
deprived of those signs which, in the adult, are developed in a single 
2)oint : as, for instance, the coarse breathing, which is of so much diag- 
nostic importance as one of the earliest signs of the deposit of tubercle 
at the apex of the lungs. 

Another source of difficulty and error lies in the fact already alluded 
to, that the bronchial glands, when enlarged by the deposit of tubercle, 
as so constantly happens in conjunction with the pulmonary phthisis of 
children, are brought into contact with the thoracic walls, and transmit 
many sounds with intensified force. It is thus that prolongation of the 
expiratory sound beneath the clavicle, and jerking respiration, lose much 
of the importance they have as signs of the early stage of phthisis in 
adults. For although, when heard in children, they should always be 
regarded as probable evidence of phthisis, they have frequently been 
noticed in cases whose progress shows the tubercular deposit to have 
been, at the most, trifling. In the same way, caution must be used not to 
mistake the blowing sound, mixed with moist rales, which is thus trans- 
mitted from a compressed bronchial tube containing mucus, for a large 
tubercular vomica. The only way in which this mistake, and the con- 
sequent too unfavorable prognosis, can be avoided, is by comparing daily 
the results of auscultation and percussion, and noticing whether they 
remain exactly the same, or whether, while the dulness on percussion over 
the enlarged glands persists, the results of auscultation vary from day to 
day with the varying amount of compression of the bronchus and the 
nature of its contents. 

A still further source of difficulty results from the loss of all the in- 
formation which is derived, in older persons, from the vocal resonance 
and its alterations. And again, owing to the excitability of children, 
patient and prolonged observation is required, both as to the situation, 
degree, extent, and duration of any inequality of breathing, before any 
conclusion can be drawn from it. 

Finally, the extreme resonance of the thorax in early life tends to 
vitiate the results of percussion by preventing the recognition of fine 
variations of sonority, such as are readily detected in more advanced life. 

In addition, moreover, to these numerous sources of difficulty in the 
application of auscultation and percussion, we are compelled to add the 
fact that there is not a single physical sign peculiar to pulmonary phthisis 
in children ; the dulness in the interscapular space in bronchial phthisis 



652 TUBERCULOSIS. 

being indeed the only characteristic sign developed in either form, and 
even this does not appear until the glands have attained a very large size. 

We have thus far been considering the symptoms of pulmonary phthisis 
in its usual moderate^ acute form, but it is necessaiy to be aware that 
in some cases it deviates from this course, beiug at one time extremely 
rapid, and at another very chronic in its progress. 

In the acute cases, we often find that there has been a previous deposit 
of tubercle in different parts of the economy, though to so small an extent 
as scarcely to have interfered with nutrition or the performance of the 
functions, or to have attracted the least attention. 

In such a state of system, death ma} r be produced in a few clays or 
weeks by an acute development of tubercle. When this occurs in the 
lungs, it is not unfrequently attended by inflammation of the pulmonary 
parenchyma, constituting tuberculous pneumonia; and, whatever may be 
the view entertained as to the relation between the inflammation and the 
tubercular deposit, the recognition of this latter element is of the greatest 
importance, from its bearing on the treatment to be adopted. 

In tuberculous pneumonia, in addition to the hereditary tendency and 
past histoiy of the child, we rarely find the same heat of skin or vascu- 
lar excitement as in pure pneumonia. The degree of oppression of the 
chest is also, from the beginning, out of proportion to the catarrhal or 
bronchial symptoms with which the case sets in. And auscultation reveals 
both that the amount of inflamed lung-tissue is not sufficient to account 
for the ctyspncea, and that the rales developed are of the subcrepitant and 
mucous varieties, rather than the true fine crepitant rale of uncomplicated 
pneumonia. 

In the chronic form of phthisis alluded to, the s3 T mptoms msij be pro- 
longed during several years. The}" consist of progressive emaciation, 
chronic cough, with or without expectoration according to the age of the 
patient, and the physical signs of more or less advanced tubercular de- 
posit. In favorable cases, it is not unusual for some degree of temporary 
improvement to occur in the general symptoms, and in some rare cases 
the child slowly regains good health, and the physical signs gradually 
diminish, leaving merely some dulness and feeble respiration at points 
where positive signs of advanced tuberculous disease previously existed. 

Symptoms of Tuberculous Peritonitis. — The peritoneum may either 
become implicated late in the course of general tuberculosis, or it may 
be the first structure involved. Apart, however, from the general symp- 
toms of the tuberculous cachexia which in some cases precede its appear- 
ance, there are few symptoms of much diagnostic value during its early 
stage. Thus the child retains its appetite and spirits ; does not lose flesh 
rapidly ; and only complains of occasional and apparently causeless ab- 
dominal pain. This condition does not, however, last long; the nutrition 
soon fails, the appetite becomes capricious, the bowels irregular, the 
colicky pains more frequent and severe, and the abdomen acquires an 
abnormal size and appearance. These symptoms, however, merit a more 
detailed allusion. The tongue rarely indicates, either b}" diyness or far- 
ring, any serious disturbance of the digestive functions. The bowels 



SYMPTOMS OF TUBERCULOUS PERITONITIS. 653 

are almost invariably loose, or alternations of constipation and diarrhoea 
present themselves, the stools usually being unhealtlry in appearance. 

This condition frequently appears to depend upon inflammation or 
tuberculous ulceration of the intestines. 

Vomiting is not usually present ; it is rarely spontaneous, and merely 
consists in the occasional rejection of alimentary matters. 

Pain in the abdomen has been mentioned as one of the earliest symp- 
toms. It is rarely constant or confined to the seat of the lesion, but is 
rather shifting, intermittent, and colicky in its nature, recurring with 
greater or less frequenej^. There is also tenderness on pressure over the 
abdomen, which becomes especially marked during the later stages of the 
disease, though in some cases the abdomen remains indolent throughout. 
At a variable period after the appearance of the preceding symptoms, 
and sometimes simultaneously with the occurrence of colicky pains, the 
abdomen undergoes a marked modification in its size and shape. It 
becomes tense and large, and assumes an oval or globular form, the 
depressions and fossae being all effaced. It generally retains its tympa- 
nitic note upon percussion ; and in proportion as the distension increases, 
the sound becomes more and more tympanitic. The tension often varies 
without any apparent cause ; and when it is much diminished, an imper- 
fect sense of fluctuation ma}^ be obtained by filliping the sides of the 
abdomen. This sign is rarely due to any ascites being present, but is 
beyond doubt rightly explained by Rilliet and Barthez, as due to the 
transmission of the impulse of the hand by the agglutinated intestinal 
mass. 

It is onlv in very exceptional cases that even the most careful percussion 
or palpation will detect any inequalities in the abdominal walls, due to the 
presence of large tuberculous patches. In every case in which the last- 
named observers detected any abdominal tumor, the omentum was found 
to be the chief seat of the tuberculous deposit. 

After this condition of the abdomen has persisted some time, the dis- 
tended skin desquamates, and assumes a rough and dirty appearance. 
At about the same period usually, the cutaneous veins of the abdomen 
become prominent and dilated, owing to the obstruction to the abdominal 
circulation. 

As the case progresses, and the general s3^mptoms assume more grav- 
ity, these local symptoms become more pronounced. Like all forms of 
tuberculosis in children, however, the advance of this disease is rarely 
uniform, and intermissions and fluctuations in the symptoms are often 
noticed. Toward the close of life, all the symptoms usually undergo 
aggravation, and the remissions become more and more rare and brief. 

Death is either produced by the advance of tuberculous disease in the 
lungs, or b}^ tubercular meningitis ; or the little patient sinks from sheer 
exhaustion under the persistent diarrhoea and the repeated accessions of 
peritoneal disease. 

Symptoms of Tuberculosis of the Mesenteric Glands. — The symptoms of 
this condition are even less positive and diagnostic than those of tuber- 



654 TUBERCULOSIS. 

culous peritonitis. So long as the glands remain only moderately en- 
larged, buried as they are beneath the small intestine, it is impossible to 
detect their presence, especially as the absorption of chyle is not materi- 
ally interfered with. 

We have already mentioned, moreover, the comparative rarity of symp- 
toms due to the pressure of the enlarged glands upon neighboring struc- 
tures, such as perforation or compression of the intestines, and dilata- 
tion of the cutaneous veins, or oedema. 

The modifications of the size and shape of the abdomen occasionally 
furnish useful information. It is rarely so large and tense as in tuber- 
culous peritonitis, and its shape is rather globular than oval. 

There is scarcely any tenderness on pressure over the abdomen, unless 
there is some accompanying peritonitis. 

The only really pathognomonic symptom, indeed, is the detection of 
the enlarged glands by palpation. This, however, is far from being pos- 
sible in all cases, even when the bulk of the glands is very considerable, 
as they are frequently covered and concealed by the intestines. 

It is, in fact, only in those cases where the abdomen is supple and re- 
laxed, that we can establish the presence of the tumor, which is usually 
lobulatecl, varying in size from a hen's egg to a large orange, and seated 
in the neighborhood of the umbilicus. 

The digestive system here also presents more or less marked disturb- 
ances ; the bowels in particular being loose, a condition generally due to 
the existence of tuberculous ulceration of the intestine. 

The general symptoms which accompany tuberculization of the mesen- 
teric glands alone, are often not so marked as when other organs are 
affected ; in fact, MM. Rilliet and Barthez assert that they have not met 
with a case in which this affection, isolated from all others, has produced 
vaiy considerable emaciation. 

Duration. — The duration of tuberculosis in children, as might have 
been expected, varies considerably according to the position and sur- 
roundings of the patients. In large hospitals, where the children have 
not the advantage of the best hygienic influences, the majority of cases 
terminate in from 3 to Y months, though occasionally protracted to up- 
wards of 2 years. In private practice, on the other hand, many cases of 
chronic phthisis are met with, in which the disease continues for 3, 4, 
or even 5 years before producing death. It is extremely difficult to assign 
any probable duration for either tuberculous peritonitis or tabes mesen- 
terica, as they can rarely be diagnosed during the early stages of their 
development. 

Diagnosis. — The danger in regard to the diagnosis of phthisis in chil- 
dren is not so much of entirely overlooking the nature of the disease, as 
of overestimating its amount. We have already given the reasons why 
the physical signs of pulmonary and bronchial tuberculosis in children 
are less reliable and more difficult to appreciate than in adults. A proper 
attention to the hereditary tendencies and individual history of the child ; 
a close scrutiny of its physical conformation and development, with an 



DIAGNOSIS — PROGNOSIS. 655 

intelligent interpretation of the physical signs, will, however, generally 
suffice to prevent any serious error. 

In the earlier stages of the more acute forms of phthisis, the disease 
with which it is most apt to be confounded is remittent fever ; from which 
it may be distinguished hy the history of malarial exposure, by the defi- 
nite commencement of the case, and by the very marked exacerbations 
which occur towards night, attended with high fever, great heat of skin, 
and considerable delirium. In its more chronic forms, the diagnosis of 
pulmonary phthisis from chronic bronchitis is often attended with the 
greatest difficulty. In fact, the plrysical signs of the two conditions are 
frequently so entirely analogous, that it is only by the general symptoms 
of tuberculosis, the greater amount of hectic irritation, the more rapid 
emaciation, and the frequent supervention of tubercular deposit in other 
organs, that a diagnosis can be established. 

O 7 O 

TTe have already dwelt upon the value of abnormal development of the 
abdomen as a symptom of tubercular peritonitis. There are, however, 
many cases of simple functional derangement of the intestines, in which 
no suspicion of tuberculous deposit can be entertained, where this symp- 
tom is also noticed. It is due to this circumstance that tubercular disease 
of the peritoneum and mesenteric glands was formerly considered of such 
frequent occurrence. A careful regard, however, to the age of the patient ; 
for simple distension of the abdomen occurs generally in infancy, whilst 
tuberculous peritonitis is most frequent after the age of 3 years ; and to 
the effects of simple remedies, will usually remove any doubt. 

The cases which are most apt to be confounded with tabes mesenterica 
are those in which abdominal tumors, due to some other cause, are present. 
Thus, in extensive tubercular deposit in the omentum, we may have, in 
addition to the general s} T mptoms of tuberculosis, a well-defined tumor 
about the middle of the abdomen. The greater degree of tenderness of 
the abdomen, and the mobility in this case, may, however, serve to dis- 
tinguish it. Again, it is not rare to find in cases of digestive derangement, 
where irregular action of the bowels with more or less pain may have 
been present, a distinct and only slightly movable tumor in the abdomen, 
due to the impaction of the intestine with hardened feces. A careful con- 
sideration, however, of the position of these masses, which is generally in 
one or the other iliac fossa ; their entire painlessness and doughy char- 
acter upon palpation, and their complete disappearance after the admin- 
istration of laxatives and enemata, will reveal their true nature. 

Prognosis. — The very name of tuberculosis has grown, with only too 
much reason, to be almost synonymous with impending, unavoidable death. 
And yet, while pulmonary phthisis shows the same fatal tendency in 
childhood as in adult life, the prognosis is somewhat less gloom}'. For 
not only does well-directed treatment occasionally render a deposit of 
tubercle in the lungs, whose existence has been proved by the symptoms 
of the incipient stage, inert and obsolescent; but in rare cases, where the 
deposit has advanced to softening and destruction of lung-tissue, a cure 
has been slowly effected by the evacuation of the softened tubercle and 
the gradual cicatrization of the cavity. 



656 TUBERCULOSIS. 

In' tuberculization of the bronchial and mesenteric glands, moreover, 
numerous cases have been noticed where the glands have undergone com- 
plete calcification, and the progress of the disease has been arrested. 

While, therefore, the prognosis must ever be grave and unfavorable, 
we must bear in mind the possibility of recovery when the hereditary 
tendency of the child is not too strongly pronounced, and the actual 
tuberculous deposit not extensive or rapidly progressing. 

Modes of Death. — Having thus spoken briefly of the prognosis, a few 
words will suffice to call attention to the various modes in which phthisis 
brings about a fatal issue in children. 

In the majority of cases, death occurs from sheer exhaustion of the 
powers of life, from impaired nutrition and perverted functions. In a 
few instances of bronchial phthisis, death is suddenly caused by copious 
hemorrhage, owing to the perforation of one of the pulmonary blood- 
vessels. 

The immediate cause of death is frequently found in an intercurrent 
attack of bronchitis, pneumonia, or peritonitis ; while, in other cases, 
the cerebral sj-inptoms which precede the fatal event show that the mem- 
branes of the brain have become the seat of tuberculous deposit. 

It is not unusual, moreover, whether the original seat of the tubercu- 
lous deposit have been in the abdomen or thorax, for marked abdominal 
symptoms to be developed towards the close of the case; the tuberculous 
ulceration of the intestines serving to maintain an uncontrollable and 
exhausting diarrhoea. 

Treatment. — Prophylactic. — In children whose parents are tubercu- 
lous, and who in earl}* life give evidence of delicate health, the prophy- 
laxis becomes most important. The infant should be kept at the mother's 
breast up to the age of fifteen or eighteen months ; but in case the mother 
be herself tuberculous, on no account should she be allowed to nurse the 
child, for whom a healtlry wet-nurse should be immediately procured. 
B} T attention to this precaution, we have succeeded in raising children of 
tuberculous mothers, who had suckled their previous children and had 
lost them all in early life from tuberculous disease. 

As the child advances in age, every caution should be paid to its food 
and clothing, to securing sufficient exercise in the open air, and free ven- 
tilation in its sleeping apartment. When the circumstances of the pa- 
rents permit, it is of the greatest consequence that the child should enjoy 
the benefits of a country life, in some healthy, invigorating atmosphere, 
for four or six months out of every year. 

The child should further be guarded sedulously from the ailments in- 
cident to early life, and especially from hooping-cough and measles ; and 
the slightest disturbance of either the respiratory or digestive functions 
should receive prompt and careful treatment ; nor should we be tempted 
to discontinue these efforts, even if positive signs of tuberculous deposit 
appear; for the possibility of these deposits in childhood becoming latent 
or being evacuated, and the general health re-established, should never 
be lost sight of. 

Curative. — Little need be said of the treatment of fully developed tuber- 



TREATMENT. 657 

colosis in children, since the same indications present themselves as in 
adults, and call for the same remedies. The most essential points in the 
treatment are attention to all hygienic conditions, careful regulation of 
the diet, and the administration of remedies calculated to improve nutri- 
tion and primary assimilation. 

It is indeed impossible to over-estimate the importance of maintaining 
the appetite and powers of digestion ; and if these show any sign of fail- 
ing, we should resort to some of the bitter vegetable tonics, of which, per- 
haps, the combination of tincture of mix vomica, gtt. ii to v, with the 
compound tincture of gentian, rr^ xv to xxx, according to the age of the 
child, is most desirable. On the other hand, if we find reason to believe 
that any remedy we are administering disturbs the nutrition of the child, 
disgusts it, lessens its appetite, or rouses violent opposition at every dose, 
it should be instantly abandoned as producing the very effect we most 
desire to avoid. 

The child should be strongly encouraged to take nourishing food at 
regular intervals, and so soon as any of the articles of its diet become 
unattractive, other preparations of similar nature should be substituted. 
Milk should enter largely into the diet, and ought to be taken at least 
every morning and evening. Tender, finely divided meat should be eaten 
at the mid-day meal, in such quantities as the digestion will easily bear. 
If marked signs of debility present themselves, a few drachms of good 
brand}' may be taken at intervals through the day, with advantage. 

When the stomach does not reject it, there are few remedies whose 
action is more beneficial than cod-liver oil, given in the dose of a tea- 
spoonful or even less, three times a clay. In many instances, children 
soon become accustomed to the taste of this substance and even grow to 
relish it almost as a luxury, and to take it eagerly ; in some cases, how- 
ever, the taste is so unpleasant that the children refuse to take it, and it 
is, therefore, advisable in such instances to prescribe it in the combina- 
tion recommended at page 325, at least during the first few weeks of its 
administration. 

In those cases where it is impossible to administer cod-liver oil inter- 
nally, very good results ma}' often be obtained here, as well as under simi- 
lar circumstances in other wasting diseases of children, by the use of the 
oil by inunction. 

Iron and its various preparations are strongly indicated, and we can 
generally find some of the milder forms which will be readily tolerated. 
In those cases where there is considerable implication of the lymphatic 
glands, the syrup of the iodide of iron appears especially useful, and this 
may be well given alternately or in conjunction with iodide of potassium. 

Sea-bathing is strongly recommended, especially in the tuberculization 
of the glandular system ; or when this is not attainable, baths in which 
some tonic drug has been mixed. 

In tuberculous deposit in the peritoneum or mesenteric glands, the diet 
must be regulated with peculiar care; the most bland, un irritating, and 
digestible food being selected. If, however, despite our precautions, 
diarrhoea should make its appearance, the various astringents in combi- 

42 



658 CONGENITAL SYPHILIS. 

nation with opium should be given freely. The pain in the abdomen, 
which is frequently so severe in these forms of tuberculosis, may be re- 
lieved by the application of sinapisms, or of warm anocVyne poultices, or 
by gentle friction with a sedative liniment. 

When the symptoms of any intercurrent inflammation in the diseased 
organ present themselves, we must limit our treatment to the application 
of a few cups or leeches over the part, and the administration of a less 
stimulating diet, with some mild febrifuge. When the peritoneum is in- 
volved in the tubercular deposit, and we have reason to fear an accession 
of inflammation of that membrane, there is urgent necessity for the use 
of topical depletion in moderation ; but we must, at the same time, bear 
in mind the cachectic nature of the disease, and refrain from the adoption 
of any depressing plan of treatment. 



AETICLE YI. 



COXGE^TITAL SYPHILIS. 



Infantile sj^philis may be either inherited or acquired subsequent to 
birth. As, however, the characters of the latter form do not differ mate- 
rially from those of acquired syphilis in the adult, we shall limit our de- 
scription to hereditaiy S3 r philis. 

Careful clinical observation appears to have clearly demonstrated the 
following facts with regard to the transmission of syphilis, in addition to 
the direct contagiousness of both the primary and secondary manifes- 
tations : 

That the embryo in utero may be infected, if either of the parents 
have constitutional syphilis at the period of conception, no matter 
whether the disease be latent, or if secondary or tertiary symptoms are 
present. That if both parents are s3 T philitic the child will more surely 
suffer from the disease, and in a more severe form. That if the mother, 
though healthy at the time of conception, contract syphilis during the first 
six or seven months of pregnancy, the child will probably be infected/ 
That when the mother infects the embryo, the disease is probably more 
severe than when the father alone is syphilitic, and thus such embryos 
usually perish, and are prematurely cast off by abortion, so that the great 
majority of children with congenital syphilis have inherited it from their 
father. While the last statement is almost universally admitted, there 
are some authors, as Hutchinson, 1 who do not admit the greater severity 
of the disease when the mother is the source of contagion. Finally, that a 
syphilitic father may infect the ovum without contaminating the mother's 
system, though the mother may subsequently herself be infected by the 
embryo. 

1 Art. Constitutional Syphilis, in Keynolds's Syst. of Med., vol. i, pp. 297 and 315. 



DATE OF APPEARANCE. 659 

In very many cases, though unfortunately not in all, the infected em- 
bryo perishes, and abortion follows. When, however, such infants are born 
living, they usually present no trace of syphilitic disease at birth, but 
may appear well-nourished and health}^. Occasionally, however, chil- 
dren have been observed who presented, at the time of birth, copper- 
colored blotches upon the skin, condylomata, or mucous patches. 

In the majority of cases the first s}miptoms of the disease appear be- 
tween the fifteenth and thirtieth days after birth, though in many instances 
also during the second month. Thus, of 158 cases collected from various 
sources by Diday, 1 the disease showed itself— 

During 1st month in 86 

" 2d « 45 

" 8d " 15 

At 4th month in 7 

" 5th " 1 

» 6th " 1 

" 8th " 1 

" 1 year, 1 

" 2 years, 1 

So that 131 children out of 158 presented evident symptoms of syphilis 
before the end of the second month. 

Among the earliest evidences of the disease are the signs of failing 
nutrition. The infant, who has grown well, and has been plump and ap- 
parently vigorous for a few weeks, begins to emaciate, the features become 
pinched, the skin assumes a dry, sallow, shrivelled appearance, and pre- 
sents patches of j'ello wish-brown discoloration, especially on the prominent 
parts of the face ; the voice becomes feeble, whimpering, and plaintive, 
and the infant soon acquires a remarkable expression of premature old 
age. 

The appearance of the skin has been most minutely described by Trous- 
seau, 2 West, 3 Diclay, and others, and is in a high degree characteristic of 
the disease. 

In addition, however, to these general symptoms of malnutrition, there 
soon appear the signs of constitutional syphilis, familiarly met with in 
the adult, as well as some which are peculiar to the disease in infancy. 

The symptoms now to be described belong partly to the secondary and 
partly to the tertiary stage, for it is a peculiarity of infantile syphilis 
that the evolution of the symptoms does not follow so orderly a course 
as in syphilis of the adult. The symptoms most frequently met with are 
certain affections of the skin and mucous membranes. Among the cu- 
taneous eruptions, pemphigus is one of the most characteristic. It is 
also the first eruption to appear, not rarely being present at birth, and 
never, according to Memeyer, 4 commencing later than the end of the 
first week of life. 

i Infantile Syphilis (Syd. Soc), 189. 

2 Clin. Med., 2eme ed., 1865, t. iii, p. 291. 

3 Dis. of Children (4th Am. ed.), 1866, p. 577. 

4 Text-Book of Pract. Med. (Am. trans.), 1869, vol. ii, p. 706. 



660 CONGENITAL SYPHILIS. 

It usually appears first on the palms of the hands and soles of the feet, 
and ma}' afterwards spread to various parts of the surface. It begins as 
small round spots, of reddish color, which become converted in a day or 
two into bullae, filled with turbid fluid. These burst, leaving irritable 
excoriations, and are succeeded b} T fresh crops of similar vesicles. The 
early appearance of pemphigus is of most fatal import ; though in some 
cases recovery gradually occurs in the course of a few weeks. The other 
forms of eruption usually occur after the general symptoms of malnutrition, 
above described, have appeared. At times the eruption consists of sharply- 
defined patches of roseola or erythema of small size, of coppeiy or yellow- 
ish-red color, not disappearing upon pressure, and occurring usually on the 
abdomen, the inner surface of the thighs, or the lower part of the thorax. 

In other cases the eruption assumes a papulated form, the papules being 
quite prominent, and usually presenting a superficial desquamation. A 
form of acne, attended with the appearance of indurated pustules which 
leave little depressed cicatrices, is not unfrequently met with; and so, 
also, vesicular and pustular eruptions occur in a good many cases. The 
most frequent of these eruptions is unquestionably the maculated form, 
while dry, scaly eruptions are in particular quite rare in infantile syphilis. 
In most cases the specific character of the eruption is manifested by the 
peculiar coppery color of the macula, or of the inflamed base of the papule, 
vesicle, or pustule. In other instances the specific character of the erup- 
tion must be inferred from the coexistence of other manifestations of 
constitutional sj^philis. 

The most frequent of these, next to the cutaneous eruption, are the 
affections of the mucous membranes. Thus, coiyza, of a serious and 
most obstinate form, is one of the most constant symptoms met with, and 
presents here all the characters fully described in our article upon that 
subject. The nasal mucous membrane is so much swollen that breathing 
and nursing are seriously interfered with. There is a profuse discharge 
from the nostrils, either of a thin, irritating fluid, which flows over the 
lip and excoriates it, or of a thicker pus, which tends to concrete and 
form thick, discolored crusts. The obstruction to respiration, and the 
accumulation of secretion in the nasal cavities, gives rise to a peculiar 
snorting or snuffling quite characteristic of the disease. 

There is apt to be, at the same time, a superficial diffuse inflammation 
of the mucous membrane of the mouth and throat, which ma} T extend 
into the larynx, causing, in conjunction with the coryza, great alteration 
in the cry or voice, which is hoarse, and has been under such conditions 
compared by West to the sound of a child's pemrr trumpet. 

Despite the severity and obstinacy of the coryza, there very rarely 
occurs any ulceration of the mucous membrane, or necrosis of the nasal 
bones, or of the hard palate. In a few cases, however, depression of 
the bridge of the nose has been observed in consequence of the destruc- 
tion of the nasal bones, and West records a case in which there was 
necrosis of the hard palate in a young infant. 

Another very frequent symptom is the formation of rhagades or fissures 
at the junction of the mucous membranes and skin, as on the lips, and at 



SYMPTOMS — ALTERATIONS OF THE TEETH. 661 

the verge of the anus. These rhagades bleed upon stretching of the parts, 
and by their laceration so much pain is caused that, when the mouth is af- 
fected, the child dreads to smile, talk, or suckle; and when they are seated 
on the anus, defecation is attended with extreme suffering. Occasionally 
rhagades form in the skin in the flexures of the joints, and especially in 
those of the fingers and toes. 

Condylomata are also frequently present, and like the rhagades are 
most frequent at the orifice of the anus and mouth, though they may also 
form elsewhere upon the skin, as upon the vulva, between the scrotum 
and thighs, in the axillae, and behind the ears. 

In consequence, probably, of the softening and ulceration of these 
growths, large, sinuous, irregular ulcers may form in such positions, ex- 
tending for some distance into the surrounding skin. 

In a few cases iritis occurs ; and so too the deeper seated tissues of the 
globe, as the vitreous humor, retina, or choroid, may become inflamed. 

Death very frequently ensues before the end of the first year, either in 
consequence of the severity of the coryza and the inability to nourish 
the little patient, or in consequence of the profound cachexia and anaemia, 
or the development of some of the visceral lesions, to be hereafter de- 
scribed. When, however, owing to judicious treatment, or the compara- 
tively slight development of the early sj^mptoms, the child survives, the 
disease frequently subsides about the end of the first year; but often, 
after remaining latent for a variable time, reappears in the form of ter- 
tiary symptoms. According to Hutchinson, this tertiary epoch may begin 
at any period after the fifth year, but is commonly delayed till at or near 
the period of puberty. In addition to the traces which may remain of 
the earlier symptoms, such as little pits and scars upon the skin, altera- 
tions in the form of the nose from long standing nasal obstruction, or 
actual disease of the nasal bones, there are several very characteristic 
symptoms amongst the later manifestations. 

Among these is a peculiar alteration of the permanent incisor teeth, first 
described by Mr. Jonathan Hutchinson. Although we are not altogether 
disposed to attach the overpowering weight which Mr. Hutchinson does 
to the evidence, furnished by this alteration of the teeth, of the existence 
of inherited S} T philis, there is no doubt that it is an important sign, and 
we, therefore, quote in full his description of it (loc. cit., p. 31 1) : 

"In these patients (those suffering with inherited syphilis), it is very 
common to find all the incisor teeth dwarfed and malformed. Sometimes 
the canines are affected also. These teeth are narrow and rounded, and 
peg-like; their edges are jagged and notched. Owing to their smallness, 
their sides do not touch, and interspaces are left. It is, however, the 
upper central incisors which are the most reliable for purposes of diag- 
nosis. When the other teeth are affected these very rarely escape, and 
very often they are malformed when all the others are of fairly good 
shape. The characteristic malformation of the upper central incisors 
consists in a dwarfing of the tooth, which is usually both narrow and short, 
and in the atrophy of its middle lobe. This atrophy leaves a single 
broad notch (vertical) in the edge of the tooth, and sometimes from this 



662 CONGENITAL SYPHILIS. 

notch a shallow farrow passes upwards on both the anterior and posterior 
surface nearly to the gum. This notching is usually symmetrical. It 
may vary much in degree in different cases ; sometimes the teeth diverge, 
and at others they slant towards each other. In a few rare cases, only one 
of the upper central incisors is malformed, the other being of natural 
shape and size. It is only in the permanent set that such peculiarities 
are to be observed ; the first set are liable to premature decay, but are not 
malformed." 

Another valuable symptom of inherited syphilis at this stage, and one 
which never occurs in acquired S3 T philis, is a peculiar form of keratitis, 
or inflammation of the cornea, which has been termed interstitial or 
syphilitic. It also is usually symmetrical, and is attended by opacit}^ of 
the cornea? from the formation of lymph in their substance. The inflam- 
mation usually subsides in a few weeks or months, leaving slight cloudy 
opacities here and there in the substance of the cornea. 

Occasionally also there are symptoms indicative of grave visceral dis- 
ease. The liver and spleen may be found enlarged and firm, and in such 
cases ascites is not rare. So too affections of the nervous system, usually 
limited to a single pair of cerebral nerves, as the auditory, and causing 
deafness, or the optic, and causing amaurosis, are met with in some in- 
stances. 

Even now marked disease of the bones is rare, though nodes quite 
frequently form upon the long bones ; and in some few cases the disease 
breaks out in the form of destructive lupus, or of serious disease of the 
bony tissues. 

Morbid Anatomy. — The principal lesions found in the victims of in- 
herited sj-philis, are in connection with the liver and lungs ; more rarely 
other organs, as the brain or thymus gland, present evidences of disease. 
The liver is at times enlarged, rounded, and indurated, apparently the 
result of diffuse subacute hepatitis, or of infiltration of the organ with the 
peculiar albuminous substance, called " amyloid," by Yirchow. It is 
comparatively rare in children to find gummy tumors developed in the 
substance of the liver, with thickening and cicatricial puckering of the 
capsule, as are so often met with in visceral syphilis in adult life. 

In the luogs, gummy tumors of various sizes form, and usually present 
cheesy degeneration of their central portion ; and there is at times also 
a form of consolidation, called by Yirchow " white hepatization," which 
depends upon chronic catarrhal pneumonia, with infarction of the air- 
vesicles with epithelial cells, in a state of partial cheesy degeneration. 

More rarely, gummy tumors have been found in the substance of the 
brain. The thymus gland is occasionally the seat of suppurative inflam- 
mation, so that on section abscesses may be detected in the substance 
of the organ. Of course in cases where periostitis with the formation of 
nodes has been present, the ordinary appearances of such lesions will be 
presented. 

Diagnosis. — During the presence of the early symptoms, the diagnosis 
is usually made with ease, by observing the presence of pemphigus soon 
after birth ; of other eruptions, with copper-colored discoloration of the 



DIAGNOSIS — PROGNOSIS — TREATMENT. 663 

skin, appearing a few weeks later ; of condylomata and rhagades ; and of 
eoryza. stomatitis and laryngitis. The general symptoms are also peculiar, 
especially the physiognomy and the discoloration of the skin. And we 
should, in addition, endeavor to confirm our suspicion hy obtaining a clear 
history of the parents' condition at the time of conception. 

During the later periods of the disease, at or after the period of pu- 
berty, the diagnosis is no less important, and far more obscure. We must 
now rely upon the history of the case, upon the condition of other chil- 
dren of the same family, upon the detection of traces of the earlier 
s\miptorns, upon the presence of the peculiar alteration of teeth described 
by Hutchinson, of interstitial keratitis, of nodes, or of a symmetrical 
aifection of some of the cranial nerves. 

In deciding between the inherited or acquired nature of any case, the 
points which will aid us are, the existence of primary disease of the 
mother at the time of delivery (which is rare, and can rarely be discov- 
ered even if it have been present) ; the existence of secondary contagious 
sj'mptoms on either the mother or the nurse who suckled the infant ; the 
presence of notched incisor teeth or of interstitial keratitis, which are 
peculiar to the inherited form; and the symmetrical distribution of all 
the secondary and tertiary manifestations, which is asserted by Hutchin- 
son to be also an attribute of inherited as distinguished from acquired 
syphilis. 

Prognosis. — The most unfavorable conditions in inherited sjqDhilis are, 
the infection of both parents ; the appearance of the disease soon after 
birth, especially in the form of pemphigus ; and the occurrence of rapid 
and extreme emaciation. On the other hand, if the father alone has 
secondary symptoms and those of a mild character ; if the disease do not 
make its appearance till the third or fourth week; if the general nutrition is 
not greatly impaired, and if proper treatment can be immediately insti- 
tuted, the prognosis is favorable, at least as regards preservation of life. 

Treatment. — If the previous children of a mother have proved syph- 
ilitic, it is well to subject her to a mild mercurial course during her preg- 
nane}^. 

In the treatment of the infant, every care must be paid to supporting 
its strength by the most nutritious diet, if it is unable to suckle the 
mother. It is, however, improper to employ a wet-nurse, on account of 
the danger of her being infected by the child. 

In regard to medicinal treatment, the use of mercury is universally 
recommended during the presence of marked symptoms. The mercurial 
may be given either in the form of hydrarg. cum creta ; calomel ; or 
bichloride of mercury, in solution in some aromatic water, or in syr. sarsae. 
comp.; or, finally, it ma}^ be introduced into the sj^stem in the form of 
mercurial ointment by inunction. The most convenient mode of intro- 
ducing it in the latter form, is by smearing a flannel roller with mercurial 
ointment and binding it around the child, whose movements cause its 
speedy absorption. 

The dose of the mercurial should be small, and it is to be continued 
steadily, though with caution to avoid producing salivation, until a de- 



664 CONGENITAL SYPHILIS. 

cided improvement in the symptoms manifests itself. During its admin- 
istration it will frequently have to be temporarily discontinued, on account 
of gastro-intestiual irritation. 

So soon as the mercury is stopped, we should order the iodide of po- 
tassium or iodide of iron, either one or both together being emplo} T ed, 
according to the toleration of the stomach. 

We should also recommend the use of cod-liver oil, and some prepara- 
tion of cinchona, from an early period in the case ; and even when the 
child suckles, a certain amount of Liebig's cold extract of meat, or of raw 
beef scraped finely and given as directed at page 3*73, should be admin- 
istered. 

The best local application to the sores is black-wash, though the con- 
dylomata usually require to be touched occasionally with solid nitrate of 
silver. 



CLASS VI. 

ERUPTIVE FEVERS. 



ARTICLE I. 

SCARLET FEVER OR SCARLATINA. 

Definition; Frequency; Forms. — Scarlet fever is an epidemic and 
contagious exantherne, characterized by continued fever; by a scarlet 
rash, which, appearing on the first or second day of the disease, ends 
usually about the sixth or seventh, or in rare cases as late as the tenth, 
and is followed by desquamation ; and by simultaneous inflammation of 
the tonsils, and of the mucous membrane of the mouth and pharynx. 

The frequency of the disease is exceedingly variable in different years, 
owing to its epidemic nature. This may be readily seen by a glance at 
the following table, which gives the annual mortality for the past sixty 
years in this city, from scarlatina and measles : 





Scarlatina 


. Measles. 




Scarlatina. 


Measles. 




Scarlatina. 


Measles, 


1809 


3 





1829 


9 


53 


1849 


242 


27 


1810 


2 


1 


1830 


40 


7 


1850 


440 


72 


1811 


3 


2 


1831 


200 


23 


1851 


391 


17 


1812 


1 


20 


1832 


307 


118 


1852 


434 


90 


1813 





1 


1833 


61 


1 


1853 


388 


14 


1814 





9 


1834 


83 


7 


1854 


162 


62 


1815 





7 


1835 


305 


248 


1855 


163 


24 


1816 





2 


1836 


240 


4 


1856 


992 


141 


1817 








1837 


205 


49 


1857 


704 


66 


1818 


1 





1838 


134 


123 


1858 


241 


28 


1819 


2 


108 


1839 


225 


136 


1859 


232 


51 


1820 


31 


47 


1840 


244 


2 


1860 


591 


15 


1821 


13 





1841 


83 


119 


1861 


1190 


74 


1822 


9 





1842 


220 


24 


1862 


461 


109 


1823 


11 


156 


1843 


395 


1 


1863 


275 


82 


1824 


9 


102 


1844 


269 


3 


1864 


349 


90 


1825 


9 


38 


1845 


199 


90 


1865 


624 


54 


1826 


4 


101 


1846 


221 


6 


1866 


491 


221 


1827 


1 


9 


1847 


344 


77 


1867 


367 


83 


1828 





58 


1848 


172 


99 


1868 


224 


108 



It will be noticed that for five successive years, 1813-17 inclusive, not 
a single death from scarlatina is reported; and that during twenty 3-ears, 



666 SCARLET FEVER. 

1809-28 inclusive, only 99 deaths occurred from this cause ; while in the 
single years 1856 and 1861, 992 and 1190 deaths respectively are re- 
ported. During the entire series of sixty y ears, there have been 13,016 
deaths from scarlatina returned. 

Hillier states, that during the eighteen years from 1848 to 1866, the 
deaths from scarlatina in London amounted to 52,461. 

It is impossible to estimate the actual relative frequency of scarla- 
tina and measles, owing to the absence of any returns of non-fatal cases. 
It is evident, however, from the above table that, although the mortality 
from measles is also very variable, and thus may for a short time exceed 
that from scarlatina, in a long series of years the latter disease is far the 
more fatal. Thus the number of deaths from measles, in this city, during 
the past sixty years, amounts to but 2279. 

MM. Guersant and Blache (Diet, de Med., t. 28, p. 113) state that it is 
less frequent than measles or variola. They added together the cases of 
the eruptive fevers collected in 1838 and 1839, by MM. Roger, Rilliet 
and Barthez, and Barrier, in the Children's Hospital at Paris, and found 
that there had only been 157 of scarlet fever; whilst there were 267 of 
measles, and 213 of variola and varioloid. 

The forms of the disease generally enumerated are the simple, anginose, 
and malignant. Authors differ widely in their descriptions of these three 
forms. Many of the English authors include in the simple form onlj x the 
cases in which there is no affection of the fauces, while the anginose form 
includes all in which there is any throat affection whatever. M. Rayer, 
on the contrary, describes under the head of the simple form the cases in 
which the throat affection is mild, while he considers the anginose form 
to be that in which a pseudo-membranous angina occurs. Again, the 
descriptions of the malignant form are vague and uncertain, some in- 
cluding under this term only the rapidly fatal cases in which cerebral 
symptoms are present, while others include those also which are rendered 
malignant b} 7 the occurrence of pseudo-membranous angina. 

We believe this division of scarlet fever into distinct forms and varie- 
ties to be, for several reasons, a faulty arrangement. It is not, it appears 
to us, in the first place, consonant with the nature of the disease. Scarlet 
fever is, in fact, with all its degrees of severhVv, and apparent differences, 
a single and distinct fever, produced by one cause, determining similar 
effects, howsoever much they may vary in degree, and requiring no more 
than does t3 T phoid fever to be divided into the variety of different forms, 
which it has been customaiy to ascribe to it. Again, the above mode of 
division is not, we are sure, a good one for practical purposes. It is im- 
possible, indeed, as we have often found it, to refer many cases we meet 
with in practice, clearly and satisfactorily to any one of the forms of the dis- 
ease described in books. The simple form of some of the English writers, or 
that in which there is no anginose affection, has no existence whatever, 
so far as we have been able to discover. We believe that inflammation 
of the mucous membrane of the fauces constitutes an essential element 
of the disease ; for we have never } T et seen a case of scarlatina in which 



FORMS. 667 

it was not present to a greater or less extent. It is often very slight, so 
slight, indeed, as to be unaccompanied by any evidence of pain in the 
part, but in all that we have examined, it has been decided and obvious. 
This supposed form of the disease does not, therefore, in our opinion, 
exist. 

The two other forms usually described, the anginose and malignant, 
are also of little value practically, since we have found that in all severe 
or grave cases, in which the patient did not die with violent nervous 
symptoms under the first shock of the scarlatinous poison, there has been 
developed a severe and dangerous anginose inflammation about the third 
or fourth day ; so that it is fair to sa}^ that we cannot imagine any malig- 
nant case, lasting over the third or fourth day, which is not anginose, 
nor any severe anginose case, which might not also be styled, from its 
dangerous character, malignant. We have found it impossible, in our 
experience, to draw the distinction clearly and indubitably between the 
anginose and malignant varieties, because all severe cases partake more 
or less of the features of both. 

Feeling this difficulty of describing the disease according to the mode 
that had before that time been generally followed, and believing it also to 
be insufficient for practical purposes, we were led to attempt, in the first 
edition of this work, a different arrangement. 

We made, accordingly, two forms or degrees of the disease, which we 
designated by the terms regular and grave. In the first form or degree 
we included all the cases in which the angina was simple and the erup- 
tion regular in all respects ; in which there was no predominance of one 
set of sj'mptoms over another, but in which all held a due relation to each 
other. In this form was embraced all the cases of scarlatina simplex of 
writers, and many of those of scarlatina anginosa of the English authors. 
In the second form we included the cases which departed from the regular 
course of the disease, and which were rendered dangerous by the occur- 
rence of severe S3'mptoms not belonging in the same degree to the simple 
affection. This form we subdivided into two varieties, the grave anginose, 
which contained all the cases accompanied by pseudo-membranous, ulcera- 
tive, or gangrenous angina ; and the grave cerebral, which comprised all 
those marked by the early occurrence of dangerous cerebral symptoms. 
The grave form comprehended, therefore, some of the cases of scarlatina 
anginosa, and all those of scarlatina maligna of writers, dividing, how- 
ever, those in which a pseudo-membranous, ulcerative, or gangrenous 
angina determined the type of the attack, from those in which the cere- 
bral or nervous s} T mptoms gave to the case its stamp. 

More extended observation and more patient reflection have taught us 
that this division also is incorrect, — that it does not afford a good classi- 
fication for the purposes of description, and that it is defective as a guide 
in practice. 

We adopted, therefore, in the last edition, and shall follow in the present 
one, a different method of considering the disease, one which we believe to 
be more consistent with its nature, more suitable for the purposes of descrip- 



668 SCARLET FEVER. 

tion, and much more likely to prove useful in practice. We shall follow 
the same arrangement in regard to scarlet fever as that now generally 
emplo} T ed for tj^phoid fever. We shall consider it as a single and dis- 
tinct disease, and not as made up of a number of uncertain and imper- 
fectly separated forms or varieties, all of which so run into each other, 
as to make it absolutely impossible to draw the line clearly and palpably 
between them. The only division we shall make will be into mild and 
grave cases, since the only real difference between the cases is a differ- 
ence in the degree of severity they exhibit. 

Causes. — It has been abundantly proved by long and reiterated obser- 
vation that scarlatina is propagated by two causes, contagion, and epi- 
demic influence. Of these two modes of propagation, we have not the 
least doubt ourselves that the latter is b} T far the most active. It is only 
necessary to look over the results afforded by the tables of mortality for 
this city, as quoted in the early part of this article, and to observe that 
in some years the disease caused a heavy mortality, in others a very small 
one, and that in others again not a single death from it is reported, to be 
convinced that it is of a highly epidemic nature. 

The contagious character of scarlatina has been doubted by some few 
persons, but seems to us clearly proved by the evidence adduced by 
various writers. Our own experience also convinces us that it is a con- 
tagious disease, though much less so, we are sure, than either small-pox, 
measles, hooping-cough, or chicken-pox. We have quite frequently, in- 
deed, known children exposed directly and for a considerable length of 
time to the infection to escape entirely, while it is extremely rare for us 
to meet with children, unprotected b}^ previous attacks, who can resist 
the contagion of measles, hooping-cough, or varicella. But, though we 
believe it to be much less highly contagious than has been generally 
supposed, and than the other contagious diseases "just named, we are 
also well convinced, as was stated above, that it is propagated to a 
considerable extent by a direct contagion. We have, in a number of in- 
stances, known one child in a family to contract the disease from direct 
exposure to it, or from the epidemic constitution of the atmosphere, and 
a second, third, and even a fourth, to take the disease from the first, in 
five, seven, or nine days after the latter had fallen sick. In other in- 
stances, on the contrary, it would seem that either several children in 
one family contract the disease nearly simultaneously from the epidemic 
influence, or else that the period of incubation is sometimes very short. 
For example, during the winter season, a child five months old, who had 
never been out of the house, was seized with it. On the second day after 
the eruption appeared on this child, her sister, between four and five 
3^ears old, fell sick, and on the third day another sister, the only remain- 
ing child, between two and three years of age. In the first of these cases 
it must have been contracted through the epidemic influence which was 
at that time prevalent in the city, since the child had in no way been 
directly exposed to it. In the other two, we must either suppose the 
cause to have been the same, or else that the period of incubation was 
only two and three days in the respective cases. 



PERIOD OF INCUBATION — MODES OF COMMUNICATION. 669 

The period of incubation is shorter than in other contagious eruptive 
diseases. It may be stated to vary between twenty-four hours and two 
or three weeks. MM. Guersant and Blache are of opinion that in the 
majority of cases, it is from three to seven days. MM. Rilliet and Bar- 
thez found that of 38 cases in wmich the time was recorded, it was be- 
tween 2 and 7 days in 16, between 8 and 13 in 15, and 15 and 40 in 8 
cases. Our own observation would fix it at from 9 to 15 days in the 
majority of cases. 

Occasionally, however, it is very short ; thus Trousseau mentions a 
case in which the evidence is almost conclusive that the period of incuba- 
tion was less than twenty-four hours. Murchison also states that this 
latent period varies from a few minutes to five days, rarely, if ever, ex- 
ceeding six days. 

It is impossible to state with any certainty the length of time during 
which the power of imparting the contagion continues in the patient. M. 
Cazenave (Abrege Prat, des Mai. de la Peau, p. 54), states that it lasts 
throughout the period of desquamation, and that it would even seem to 
be most active at that time. 

Whatever may be the duration of this period, it is certain that the virus 
can attach itself to clothing, bedding, or furniture, and that the disease 
can thus be transmitted by a third person who is not himself attacked. 
We also learn from some remarkable instances, as, for example, from a 
case related by Richardson in " The Asclepiad," that when the virus is 
thus attached to fomites, it may retain its activity for many months. 

In regard to the essential nature of the poison, it appears probable, in 
the first place, that it is contained in the secretions of the skin and fauces. 

The distance to which it ma}^ be carried by the air does not appear to 
exceed a few feet, and in those cases where prompt isolation does not 
prevent the communication of the disease, the virus has either been pre- 
viously imbibed or is carried by fomites. It is probably of material na- 
ture, and is admitted to the s}^stem either through the skin, the respira- 
tory, or, perhaps, the gastric mucous membrane. 

As we have seen, it retains its activity for a long time ; but is rendered 
inert by a temperature somewhat below 212° F. 

Scarlatina is stated to be also inoculable, by the blood, the secretion 
from the fauces, and the fluid from the miliary vesicles which occasion- 
ally form on the skin. The resulting disease appears in some instances 
to have been favorably modified, but the operation has been comparatively 
rarely practised. 

The epidemics of scarlet fever vary exceedingly in their extent and 
violence. During the years 1842 and 1843, the disease prevailed veiy 
extensively in this city, and assumed a malignant type, so that in a con- 
siderable number of families, two, three, and even four children, died 
within a very short period. 

During the winter of 1856— T, and throughout the spring of 1857, we 
had one of the most prevalent epidemics that ever visited this city, and 
yet the proportion of deaths to the whole number of cases in our own 



670 SCARLET FEVER. 

practice and that of our friends, was such as to seem to show that the 
t3'pe of the epidemic was mild. 

The disease prevails at all seasons, but is most frequent in the spring 
and summer, and next in the autumn. It rarely occurs more than once 
in the same individual, but that it does so sometimes, is proved b} T facts 
brouo-ht forward lyv different authors. It has been asserted that second 
attacks of scarlet fever occur in the same person not more than once in 
a thousand cases. Of the truth of this assertion we are, however, very 
doubtful, since it has occurred to us to see no less than three examples 
of second attacks in our own experience. We attended in this city one 
child with perfectly well-marked scarlet fever, attested by subsequent 
anasarca, who had had the disease two } T ears previously under the care 
of the late Prof. C. D. Meigs. In the winter of 1852, we attended two 
children in one famil} T with the disease, one of whom died, and both of 
whom had had the disease four years and a half before. They were at- 
tended in the first attack by one of ourselves, and as it chanced, owing to 
our absence from town during one da} T , they were seen also by one of our 
friends, who made no exception whatever to the diagnosis of scarlet fever. 
The only doubt as to these cases having been veritable examples of double 
attacks of the disease, must rest of course upon the diagnosis. In the 
first example, the diagnosis was made by Prof. Meigs in the first attack, 
and b} r one of ourselves in the second. In the two latter it was made by 
one of ourselves in both, accidentally confirmed in the first attack, in both 
children. b} r the opinion of a competent professional friend. The first at- 
tacks in the latter cases were both mild, but well marked ; the second were 
both severe, and one proved fatal on the sixth clay. We have not the least 
doubt ourselves that all of the three were cases of true scarlet fever. If 
they were not, the two latter must have been cases of roseola, so closely 
resembling scarlatina as to oblige us to confess ourselves incompetent to 
distinguish between the two diseases. What adds to the certainty that 
the two which came under our own observation were examples of scarlet 
fever, is the fact that the} T occurred simultaneously with a third case in the 
same family. Now, roseola is not apt, so far as we know, to occur epi- 
demically in a household. Most of the cases of that disease that we have 
seen, have been solitaiy ones. Again, in the spring of 1857, one of us 
saw a well-marked attack of the disease in a boy nearly four years old, 
who had had it one year* before, under the charge of a perfectly com- 
petent practitioner. 

Dr. Richardson (loc. cit.) asserts that he has known the disease to occur 
twice in the same patient, and also states that he himself has suffered 
from it three times. 

Age. — MM. Rilliet and Barthez state that it is most common from six 
to ten years of age. Of 251 cases that we have seen, in which the age 
was noted, 64 occurred under 3 years of age, 78 between 3 and 5 years, 
51 between 5 and 7, 47 between 7 and 10, and 11 between 10 and 15. 
From this it would appear to be more common in the first five years than 
between the ages of five and ten, since of the 251 cases, 142 occurred in 



INFLUENCE OF AGE — SYMPTOMS. 671 

the former, and only 98 in the latter period. By uniting the statistical 
tables of Dr. Emerson with those of Dr. Condie (Dis. of Child., 2d ed., 
note, p. 86), we obtain the deaths from scarlatina in this city at different 
ages for a period of thirt}- years. These tables show clearly that the dis- 
ease is most common between the ages of one and five 3^ears. The total 
mortality from sealatina under ten j^ears, during the time stated, was 
2171, of which 132 were under one year of age, 411 between 1 and 2, 1130 
between 2 and 5, and 510 between 5 and 10. 

Of 148,829 cases collected by Dr. Murchison from the death returns of 
Great Britain, 9999 or about 7 per cent, were under 1 year; 30, 9*74 or 
20 per cent,, under 2 } T ears; 95,070, or 64 per cent, under 5 years ; 38,591, 
or 26 per cent, between 5 and 10 ; and but 13,168, or about 9 per cent., 
at all ages above 10. 

This agrees quite closely with the averages calculated from the extensive 
statistics collected by Dr. Richardson, which show the following percent- 
age at different ages : 

Under 5 years, 67.63 

From 5 to 10, 24.48 

" 10 to 20, 5.52 

" 20 to 40, 1.73 

" 40 upwards, 0.66 

Out of 12,962 deaths under 5 years, 1289 or 9.9 per cent., were under 
1 year; 2874 or 22 per cent,, between 1 and 2 ; so that 4163 or 31.4 per 
cent,, were under 2 j-ears. 

The earliest age at which we have seen it perfectly well marked, was 
twenty-one days. We saw it once also in a child five months of age, and 
twice at the age of six months. It is not nearly so common in the first 
year of life as it is afterwards. The largest number of cases occur, ac- 
cording to our experience, in the third, fourth, and fifth years of life. 

The influence of sex seems not to have been determined with certainty. 
Dr. Tweedie (Cyclop, of Tract. Med., art. Scarlatina), says it is most 
common in girls. MM. Rilliet and Barthez, on the contrary, state it to 
be more common in boys. Of 262 cases under 15 years of age that we 
have seen, in which the sex was noted, 133 occurred in males, and 129 in 
females. The truth is, probably, that under puberty it attacks the two 
sexes with about equal frequency, while after that age it is most common 
in females. 

It occasionally happens, that patients, both adults and children, who 
have undergone surgical operations, are attacked with a scarlatinous rash, 
with mild constitutional symptoms (Hillier, Gee). The disease, accord- 
ing to these authorities, is true scarlatina; and its occurrence at that time 
probably depends upon the system being in an unusually favorable con- 
dition for the reception of the virus. 

Symptoms ; Course ; Duration. — As has already been stated, we in- 
tend, in our description of the symptoms of scarlet fever, to depart from 
the ordinary mode of arrangement of the subject. We shall discard the old 
division of the disease into three forms or degrees, scarlatina simplex, 



672 SCARLET FEVER. 

anginosa, and maligna, and substitute, for reasons already given, the 
simple division into mild and grave cases. We shall class as mild cases 
those which pursue an even and regular course, without being accompa- 
nied by dangerous or malignant s3 T mptoms, in which there occur neither 
violent nervous, nor threatening anginose symptoms ; while among the 
grave cases we shall place those in which there occur severe nervous 
sj'Hiptonis, in the form of violent delirium, coma, or convulsions, danger- 
ous symptoms in the form of diphtheritic, ulcerative, or gangrenous in- 
flammation of the mucous membrane of the fauces, and finally, those in 
which the general symptoms assume a low and typhous character. When 
it seems convenient, we shall follow the usual division of the course of 
the disease into the three stages of invasion, eruption, and desquamation. 

Mild Cases. — Stage of Invasion. — The following description of the 
symptoms of scarlet fever in its mild form is drawn partly from books, 
but much more from our own observation of 206 mild cases of the disease, 
of all of which we have kept a faithful record, and when there was any- 
thing peculiar or important, full notes. 

The onset of mild cases of scarlet fever is generally sudden. A child 
is well, or so slightly ailing on one dajr, as that the change from its usual 
condition is not noticed at the time, though it ma}^ be recollected after- 
wards, and on the following day, or often within twelve hours or even less, 
the symptoms of the disease become marked and characteristic. In a large 
majority of the cases that we have seen, the eruption was already visible 
at our first visit. Frequently the patient has been put to bed well in the 
evening, and, becoming restless and feverish in the night, is found on the 
following morning with fever, sore throat, and very considerable eruption ; 
or, as happened in one of our cases, a child gets up in the morning ap- 
parently well, breakfasts as usual, goes to church, and falling sick while 
there, comes home and a few hours later shows the eruption over the neck 
and upper part of the trunk, and has fever and sore throat. In another 
case, a boy between seven and eight y ears old was perfectly well in the 
morning. At 2 p.m., his mother, a most sensible and accurate person, 
observed him playing in the garden, and remarked upon his healthy 
looks. Fifteen minutes after this he felt sick at his stomach; he came 
into the house and went up to the nursery, looking pale and pinched, 
with a cold skin, and nearly fainted in the nurse's arms. He had then in 
the course of an hour three copious and watery stools, each one accom- 
panied with vomiting. We saw him one hour after this, dozing, very 
pale, with pinched features, sunken and half-closed eyes, cool surface, 
and with the pulse at 128, and rather feeble. There was no eruption. 
At 6 p.m. we found him with a hot and dry skin, with the tongue heavily 
coated, the fauces swollen and showing flecks of exudation upon the ton- 
sils, a pulse at 128, and with a well-marked scarlatinous eruption coming 
out abundantly. The case pursued a very regular course, without dan- 
gerous or malignant S3 T mptoms of ai^ kind. 

But the invasion, though sudden in nearly all cases, is not always so 
precipitate as we have just described. When we come to analyze the 



SYMPTOMS OF MILD CASES. 673 

early symptoms, we find that the first one observed in most of the cases 
is fever, marked by considerable acceleration of the pulse and heat of 
skin. In some few cases the fever is preceded by the ordinary prodromes 
of febrile diseases, languor, lassitude, pains in the back and limbs, and 
slight rigors. Simultaneously with the fever there is in nearly all cases 
more or less soreness of the throat. In all that we have examined, even 
those in which no pain was complained of, there has been redness, or 
redness with swelling of the fauces. In a majority of the cases vomiting- 
occurs, or if not vomiting, some degree of nausea. There is complete 
anorexia ; the thirst is acute ; the bowels are usually in their natural con- 
dition, or slightly constipated. The child is quiet and dull, or else rest- 
less and irritable, and sometimes there is delirium; the face is generally 
flushed, and the eyes often slightly injected. The duration of these symp- 
toms is irregular. They are said to last generally about a day, but they 
may continue either a shorter or longer period. We are very sure, from 
our own observation, as we have already stated, that these preparatory 
symptoms rarely precede the eruption more than twelve hours, and very 
often the time is eA'en less, so that the eruption may even be the first 
symptom noticed. 

Stage of Eruption. — The eruption generally appears first on the face 
and neck, whence it extends rapidly over the whole surface. It con- 
tinues to increase in extent and intensity,, so as to reach its maximum 
about the third or fourth day. It appears first in minute dark-red points 
dotted upon a rose-colored surface, forming patches of irregular shape, 
of considerable size, level with the skin, disappearing under pressure, 
divided at first by portions of healthy skin, but running rapidly together, 
and giving to large portions of the surface a uniform scarlet color. The 
eruption is not generally equally diffused over the whole body, but is more 
marked upon one portion than another. It is often most intense on the 
back, and is there of a deeper color than elsewhere, not unfrequently as- 
suming a purple hue. It is generally very well marked on the abdomen 
and thighs, and about the articulations, and assumes in those regions a 
particularly bright tint. 

It does not alwa} T s cover the whole surface, but in some very mild 
cases, and, as we shall find when treating of the grave cases, in these 
latter, also, it may occur only in patches of moderate extent upon differ- 
ent portions of the body, leaving us at times in some doubt as to the real 
nature of the rash. 

The surface of the eruption is smooth and even to the touch, unless, as 
not unfrequently happens, it is accompanied by the development of mili- 
ary vesicles, or crops of minute pimples or pustules. A certain degree 
of roughness is sometimes occasioned also by enlargement of the papilla? 
of the skin in various parts of the body, particularly on the extensor sur- 
face of the limbs ; but these are evidently independent of the characteristic 
eruption. The skin upon some parts of the bocty, especially the face, 
hands, and feet, often presents a swollen appearance, rendering the move- 
ments somewhat stiff. There is in most cases a feeling of burning, irri- 

43 



674 SCARLET FEVER. 

tation, and itching in the skin, the latter of which sjmaptoms increases as 
the malady progresses. 

If the nail be drawn firmly over the skin where the eruption exists, a 
white line is produced, which lasts for a short time and then passes awa}^; 
if the pressure be more firm, a central red line with a white streak on 
either side is developed. This was originally pointed out by Bouchut as 
pathognomonic of scarlatina, the peculiarity, according to him, consisting 
in the great duration of the white line so caused. It does not appear, 
however, to have any positive value in distinguishing this affection from 
many forms of erythema. 

The eruption generally reaches its height about the fourth day, and 
then remains stationary for one, or less frequently two days, after which 
it begins to decline. Its decline is marked hj a diminution in the inten- 
sity of the color, which, from scarlet, becomes red, then rose-colored, and 
growing paler and paler, finally disappears entirely about the sixth, 
seventh, or eighth day. In some very mild cases, however, the whole 
duration of the eruption is not over two or three daj^s, and in such the 
color it imparts to the skin is never very bright nor very deep, nor is it 
accompanied by intense heat, or by much irritation or itching. 

The symptoms which preceded the eruption do not subside on its ap- 
pearance, but persist or are augmented. The febrile movement continues 
unabated ; the pulse is full, strong, and frequent, running up very soon 
after the onset to 120, 140, 150, and often to 160. This frequenc}' of the 
pulse is, in fact, one of the most marked sj'mptoms of the disease. We 
have rarely, even in very mild cases, found it less than 140, and in not a 
few it has been in the first few days, and in children of four or six 3 T ears 
old even, as high as 168 or 110. Occasional!}', however, it has been lower, 
and in a case that occurred to one of us, in a boy five years old, it was 
96 on the second day, and only 88 on the third, though there was still a 
good deal of rash upon the skin. The skin is burning hot and diy, as a 
general rule, and loses its usual softness and suppleness. The expression 
of the face is usually natural. The e}-e is often animated, and slightly 
injected. The respiration is generally easy and natural, though some- 
times when the fever is violent it becomes quickened. The auscultation 
and percussion signs are natural, unless some complication exists. There 
is often a rather frequent cough, which is dry, and evidently depends on 
the guttural inflammation, and not on any bronchial or pulmonary affec- 
tion ; it exists during the early period of the eruption, and declines with 
the inflammation of the fauces. The voice is seldom altered beyond 
having a nasal sound, so long as the disease continues simple and regular. 
If the voice becomes hoarse or whispering, it indicates an extension of 
the inflammation from the pharynx to the laiynx. The anorexia continues 
until the eruption begins to decline, and the thirst is acute up to the same 
period, when it moderates. At first the dorsum of the tongue is covered 
with a whitish or 3 T ellowish-white fur of variable thickness, while its tip 
and edges are of a deep red color. After two or three days, and during 
the course of the eruption, the coating just described disappears from the 



SYMPTOMS OF MILD CASES. 675 

tongue, and its whole surface assumes a deep red tint and a shining ap- 
pearance, which makes it look like raw flesh. At the same time it is often 
much diminished in size from contraction of its tissues, and its papillae 
become enlarged and projecting ; this condition generally lasts from six 
to ten days, after which it returns to its natural state ; it is commonly 
moist throughout the attack. Vomiting is rarely troublesome in mild 
cases, though it often occurs ; the bowels continue nearly in their natural 
condition ; in some few cases slight diarrhoea occurs, but more frequently 
there is very moderate constipation, which requires the use of mild lax- 
atives. The abdomen is natural in most of the cases ; sometimes, how- 
ever, there is slight distension and pain for a few days, which coincide 
generally with enlargement of the liver, or more rarely of the spleen. 

The urine during this stage usually presents the ordinary febrile char- 
acters ; it is diminished in quantity, often of high color, though the pig- 
ment is not necessarily increased. The urea is not increased, which 
Ringer regards as indicating that the kidneys are affected from the begin- 
ning of the attack. The chlorides are always more or less diminished. 
The phosphoric acid, according to Dr. Gee, is about normal for the first 
three or four da} T s ; it then diminishes, and remains for a few days at a 
half or a third of its normal amount. Uric acid appears to be retained 
during the p}Texia, and excreted in excess so soon as it begins to sub- 
side. According to Holder's examination of It cases, there is bile pig- 
ment present during the first six days. 

Earfr in the second, or even in the first stage, the fauces present the 
signs of inflammatory action ; the pharynx is reddened, and in some in- 
stances swelled ; the tonsils enlarge and become red ; the submaxillary 
and lymphatic glands are somewhat tumefied and tender to the touch, 
and when the case is at all severe, deglutition is generally painful, and in 
some instances extremely so. The absence of complaints of sore throat 
in a child, or the fact of its swallowing without hesitation or apparent 
difficulty, is no proof that angina does not exist, since we have always 
found upon examination in a good light much greater redness than natu- 
ral, and in many instances redness and swelling combined. As the erup- 
tion progresses, and the tongue loses its coat and becomes red, the inflam- 
mation of the phaiynx usually augments ; the redness becomes deeper,, 
and the tonsils are more swelled and painful, and in a good many, but 
not by any means all the cases, dotted over with small white spots, or 
with thin, whitish, and soft false membranes. The throat-affection, how- 
ever, is rarely severe enough to constitute a serious danger in mild scar- 
latina, while in many of the malignant cases it is a frequent cause of a 
fatal termination. During the eruption, the nostrils are either dry and 
incrusted, or there is some coryza. The strength of the child is reduced 
for the time, but there are no signs of prostration, and the decubitus is 
indifferent. There is almost always more or less disorder of the nervous 
S3'stem, sometimes amounting only to headache and restlessness, while 
in other instances there is great irritability, wakefulness, and occasional 
delirium, especially at night. 

Stage of Decline and Desquamation. — The eruption reaches its height. 



676 .SCARLET FEVER. 

as already stated, about the third or fourth day, then remains stationary 
for one or two days, and afterwards declines gradually, so that no traces 
are left on the sixth, usually, or at most in rare cases, on the ninth or 
tenth da}'. In some very mild attacks, the whole duration of the eruption 
is not over two or three days. By the third day it has disappeared en- 
tirely. Such cases are not, however, very common. The other symp- 
toms, both general and local, decline with the eruption ; the pulse loses 
its frequency, and falls to the natural standard; the heat of the surface 
first subsides and then disappears, but the skin remains somewhat harsh; 
the redness and swelling of the tonsils and pharynx diminish ; the spots 
of false membrane, if these be present, are absorbed or thrown off; the 
deglutition becomes easy if it have been difficult, and soon all signs of 
throat-affection vanish; the tongue cleans off, becomes reddish and glossy, 
and after a time returns to its natural state. 

At the time that the subsidence of all the symptoms takes place, des- 
quamation begins. It dates, therefore, in most cases from about the sixth 
day, though it roay be either earlier or later. According to Hillier, the 
date of commencement varies from the sixth to the twenty-fifth da}'. It 
commences in most of the cases on the face and neck, though in a few in- 
stances it appears first on the abdomen. It then extends gradually over 
the bod}' and becomes general. About the thorax and abdomen it occurs 
in the form of minute points, like those which result from the desiccation 
of sudaniina ; on the face it is in the form of thin light scales or squama?, 
while on the extremities large flakes of the epidermis become separated 
from the derm, and are removed by the child, or rubbed off by his move- 
ments in bed ; these flakes are sometimes so large on the hands and feet 
as to form complete moulds of the fingers and toes, or even of the hands 
and feet. The whole process usually occupies some ten or twelve days, 
but may be prolonged into the third week, or even until the middle of the 
second month. It is generally accompanied by roughness and dryness, 
and some itching and irritation of the skin. Not unfrequently, the sur- 
face beneath the exfoliation is left tender and irritable for some time 
afterwards. 

During this period, dating from the sixth or eighth day, the urine be- 
comes abundant, pale, of neutral or faintly acid reaction, and, according 
to Gee, deficient in phosphoric acid. 

Albuminuria is also frequently observed during desquamation, very 
much more so than during the eruptive stage. It is usually transient, 
but ma}' continue until dropsy occurs. Sometimes the albumen totally 
disappears, and reappears when dropsy comes on a fortnight or three 
weeks later. The proportion of cases in which this form of albuminuria 
is present varies in different epidemics, from twenty-five or thirty to 
ninety per cent. 

Temperature. — The fiery redness of the surface and the pungent char- 
acter of the heat, have led to much exaggeration in the description of the 
pyrexia in this disease. The range of temperature is indeed from 100° 
to 105°, and only in rare cases does it reach 106°. 

In 30 cases reported by Ringer (Med. Times and Gaz., Feb. 15th, 1862), 



SYMPTOMS OF MILD CASES. 677 

the temperature remained at the same point throughout the day in the 
more severe attacks ; in slighter ones, it fell in the morning and rose during 
the day. being most frequently at its highest point between 2 and 8 p.m. 
When the morning remission was marked, it indicated the approach of a 
favorable termination. The first decided fall of temperature, coinciding 
with a diminution in the eruption, occurred in the majorhy of cases on 
the fifth day, or if not on this day, it usually was deferred until the tenth 
or fifteenth. In these latter cases, however, a fall of varying extent had 
occurred on the preceding fifth da3 r s. After the marked fall on the fifth, 
tenth, or fifteenth day, the temperature remains from 99° to 101° for a 
variable time, coinciding when persistent, with continuance of the angina, 
or some one of the other lesions of the disease. If at any time after the 
complete fall of the temperature, there is any considerable elevation 
again, it indicates the development of some sequel, either an affection of 
the kidneys, throat, or one of the serous membranes. It is thus seen that 
the temperature in scarlatina tends to form arcs or cycles, usually of five 
days' duration. 

Before quitting this part of our subject, we must remark that, though 
the above is a correct description of the usual symptoms of mild cases 
of this disease, the reader would be greatly deceived should he expect 
always, and invariably, to find this exact train of morbid phenomena. 
On the contrary, the mild and the grave cases both vary so much, that it 
is impossible to describe them accurately by one or two portraits. Taking 
the above sketch as a standard of the mild cases, the observer will find 
that many fall short of it in all their features, while others deepen gradu- 
ally in their shades, so to speak, until they pass into the grave type. 
Those that are milder in their t}^pe than the above sketch, may be so in 
such a degree as to make it very difficult, and in some cases impossible, 
to determine positively whether the child has had the disease or not. In- 
deed, we doubt not ourselves that children sometimes have the disease so 
slightly, that it is not discovered by either the prrysician or parents, and, 
being protected by the attack, are in after-life classed amongst those in- 
susceptible to the disease. Our grounds for asserting this are the facts 
that some cases we have seen have been so very mild that, but for the 
existence of the disease amongst other members of the family, they might 
have passed unobserved ; and that in one instance we were sent for to see 
a patient, who had had the eruption for three days, and yet who was so 
slightly sick that he was sent for from school, to which he had gone, for 
us to see. It was a well-marked case, and the child had no troublesome 
symptoms afterwards, notwithstanding the exposure he had undergone. 

Grave cases. — The following description of the s3miptoms of grave cases 
of scarlet fever is, like that which has just been given of the mild cases, 
drawn partly from books, and partly from our own observation of the dis- 
ease. Our own experience includes the careful observation, and a more 
or less full notation, of 51 grave cases. We shall include under this di- 
vision of the subject, as already stated, most of the cases usually classed 
by writers under the title of scarlatina anginosa, and all those generally 
described under the title of scarlatina maligna. 



678 SCARLET FEVER. 

The symptoms which mark the invasion of grave cases of scarlet fever, 
though sufficiently alike in all to show the unity of the disease, differ very 
materially as to their degree of severity in different cases. In one set 
(rather less than a third, or 16 in 57, of our cases), they are most violent 
and dangerous, or, indeed, appalling in their character. From the first, 
they declare the imminent danger of the attack. In the second set (rather 
more than two-thirds, or 41 in 57, of our cases), they ma} T be either evi- 
dently severe and dangerous, though not appalling as in the first, or they 
may be much milder, more like those which mark the invasion of mild 
cases, but even under these circumstances they soon put on their grave 
and dangerous character. 

The first set of cases, or those in which the s3 T mptoms are the most se- 
vere of all, and which include most of the malignant cases ordinarily styled 
ataxic, usually begin with nervous symptoms. The onset is in some in- 
stantaneous. In one, the little patient, a girl two years old, whose bro- 
ther and sister had been sick for some days with scarlatina, was put to 
bed in the evening in her usual health, which was strong and vigorous. 
She slept quietly through the night, but was found by the mother the next 
morning in a state of drowsiness, violent fever, and covered with a deep- 
red scarlatinous rash. She soon became comatose, and died on the third 
day. In another case, a bo} r eleven months old was a little fretful in the 
afternoon, but was put to bed in the evening as usual and went to sleep. 
About ten o'clock the nurse heard a rustling in the bed, and on going to 
it, found him in a violent general convulsion. The next morning he was 
covered with a' scarlet rash, which became deeper and deeper as the disease 
went on. On the second day he was nearly insensible, and had frequent 
attacks of convulsions; on the third 4ay he had retraction of the neck, 
with spasmodic twitchings, and at the end of that da}^, died in a state of 
coma. In a third case, a boy six years old, whose sister had been sick 
for a week with a mild attack, went to bed well. At three o'clock in the 
morning, he was seized with vomiting and purging, paleness and coolness 
of the skin, and great exhaustion. At nine o'clock he was drowsy and 
dull, the skin was pale and cool, and the pulse extremely rapid ; the vomit- 
ing and purging had ceased; at 12 M. he was comatose and had a couatlI- 
sion. From this time he continued comatose until he died at 6 p.m. of 
the same day, after an illness of fifteen hours. In a fourth instance, the 
invasion was that of croup ; after a few hours came on coma and convul- 
sions ; patches of eruption then appeared on the trunk, and death occurred 
in twent t y-four hours from the beginning. The subject of this case, a boy 
five years old, was thought to be so well in the afternoon of the day he 
was taken sick, that he had been sent out to visit a relation, and while 
there fell sick. In the fifth case the onset was sudden, with violent fever, 
drowsiness, deep suffusion of the skin, and in a few hours insensibility, 
general convulsions, and death in thirty-six hours. In a sixth, in a boy 
four years old, the attack came on with vomiting, paleness, drowsiness, 
and then a scarlet rash ; after a few days, coryza and otorrhcea occurred ; 
the tongue and lips became cracked and dry ; in the second week, the child 
was comatose, with occasional attacks of extreme jactitation, and the most 



SYMPTOMS OF GRAVE CASES. 679 

violent hydrocephalic cries, which condition lasted ten days. After this 
there was diarrhoea, extreme emaciation, loss of speech, and entire deaf- 
ness. Gradually, however, the fever disappeared, the tongue cleaned off, 
and intelligence very slowly returned ; in the sixth week convalescence 
was firmly established, and the child recovered perfectly with the excep- 
tion of his hearing, which remained very dull in consequence of the per- 
foration of both membranes tympanorum. In a seventh, a girl eight years 
old, whose brother was then sick in the house with the disease, was in the 
morning well. At breakfast she said she felt sick and soon went to bed. 
At 5 p.m. of that day, she was attacked with a general convulsion which 
lasted about fifteen minutes. The pulse, immediately after the convulsion, 
was 150. At 11 p.m. she had another convulsion. Through that night, 
she was very restless and wandering. On the morning of the second day, 
there was a third convulsion, which, however, was very short. The pulse 
was now 160, small, and feeble. The patient was very heavy and dull, 
answering questions slowhy, and with great difficulty, and during part of 
the day she was comatose. On the third day, she was better, the pulse 
having fallen to 152, and she was less dull, though she still continued very 
heav} T and inattentive unless aroused by persevering efforts. The limbs 
were cool, while the head and trunk were hot. The eruption was thick 
on the trunk and upper part of the extremities ; elsewhere it was scanty. 
Wherever it existed, it was of a deep red or purplish color, and the capil- 
lary circulation was sluggish and imperfect. On the fourth cla}^, her in- 
tellectual condition continued better, but the extremities were still cold, 
and the lymphatic glands and subcutaneous tissues about, the lower jaw 
and neck had begun to swell. On the fifth day, the swelling had become 
veiy great ; the stupor had returned ; a profuse and disgusting coryza and 
otorrhcea had set in ; and the edges of the eyelids were inflamed and sore. 
On the sixth day the discharges from the mucous membranes of the head 
were very copious, and consisted of a thick, offensive, purulent fluid, in- 
termixed with dull whitish grumous particles. The patient was now 
comatose or very restless ; she swallowed with great difficulty; the swell- 
ing under the lower jaw and about the throat was enormous ; the pulse 
was rapid and small ; the eruption was very dark in tint ; the cutaneous 
circulation was slow ; the extremities were cold, and death occurred about 
the middle of this day. In another case, the subject of which was a girl 
between three and four years old, the attack began with severe inflamma- 
tion of the throat, causing great difficulty in swallowing. The rash on 
the first daj r was very extensive and of a deep red color. The child was 
drowsy and heavy, or else delirious. On the second day, she was coma- 
tose, and had strabismus and automatic movements of the limbs. On the 
third day the coma continued, and there were automatic movements of 
the extensor muscles, with retraction of the head. The eruption con- 
tinued vivid, but was of a dark red color. Death occurred in the middle 
of the fourth day, in a state of coma, without convulsions. In still another 
case, a boy, between eight and nine } 7 ears old, was attacked suddenly, 
while in good health, with vomiting, sore throat, and high fever. Twelve 
hours after the onset, he had a severe convulsion, which lasted fifteen 



680 SCARLET FEVER. 

minutes. He soon recovered from this, however, and remained perfectly 
intelligent. On the second day the rash was moderate ; there was violent 
fever, and the child was heav}- , but, when roused, still intelligent. Early 
in this day a severe fit occurred. This was most violent, as severe as the 
the worst epileptic convulsion. It lasted one hour and three-quarters. 
The pulse, after this, was 145. On the third and fourth days, the s} T mp- 
toms improved very much, the pulse having fallen to 125 and 132, but he 
continued drowsy and heavy. The eruption came out most abundantly. 
The fauces were very much inflamed and somewhat ulcerated, and the 
external lymphatic glands were enlarged, but still the swallowing was not 
difficult. On the fifth day he was not so well, being more restless and 
heavy alternately. There had now come on much difficulty in breathing, 
and some croupal sound. The latter s3 T mptom increased through the day, 
until the cbrspncea became veiy great. Deglutition now became exces- 
sively difficult ; the external swelling increased ; attacks of suffocation 
attended with the most painful and distressing jactitation came on, and 
were renewed more and more frequently ; and death occurred b}- asphyxia 
about the middle of the sixth clay. In a tenth case, in a girl five months 
old, convulsions occurred on the second day. These were followed by 
coma lasting several da}'S, and by enormous swelling of the lymphatic 
glands and subcutaneous tissues on the left side of the neck, and by a 
less degree of swelling on the right side of the neck. The glands of both 
sides suppurated and were opened, and the child finally recovered per- 
fectly. In an eleventh case, in a boy seven years old, an attack of general 
convulsions took place on the third daj^, after which there were delirium 
and coma alternately for several days, with coryza, angina, and offensive 
otorrhcea, lasting in all six weeks. The child recovered, but remained 
deaf. 

In this form of the disease, therefore, the symptoms are of the most 
virulent character. The onset is sudden. The child passes within a few 
hours from a state of apparent health, into one of the extremest danger. 
Most of the cases begin with violent fever, and great depression of the 
strength. The pulse soon becomes very rapid (140, 150, 180), or so fre- 
quent that it cannot be counted, and it is at the same time small and often 
irregular. The skin is dry and burning hot in some parts, in others cool 
or even cold. There is generally nausea or vomiting, and these may be 
violent and constant. These are accompanied in some cases, but in our 
experience, only in the severest of all, by colliquative diarrhoea and meteor- 
ism. Delirium often exists from the first, or else there is drowsiness 
and dulness of intelligence, verging gradually into coma. In the most 
violent cases, the stupor or coma alternate with convulsions, w T hich may 
cause a fatal termination in eighteen, twenty-four, or thiily-six hours. 

When a case of this kind lasts over three, or even two days, the vio- 
lence of the nervous S3 T mptoms almost always subsides ; the convulsions 
cease to recur; the delirium is less violent ; the coma gives way to drowsi- 
ness, or the patient becomes again quite intelligent and observant ; the 
pulse often falls in frequency, and the heat of skin nmy diminish, and the 
eruption assume a more favorable appearance. All the symptoms seem, 



SYMPTOMS OF GRAVE CASES. < 681 

indeed, to be more promising, and very often both the phj^sician and 
friends are greatly elated by the improvement in the patient's condition. 
Nor are these hopes always illusory, since children do recover occasion- 
ally even in cases that have exhibited the most threatening and malignant 
appearance at the moment of invasion. It happens, unfortunately, how- 
ever, in a majority of such attacks, that the improvement which takes 
place on the third or fourth day is only momentary. The nervous symp- 
toms subside, but new phenomena make their appearance in the shape of 
severe inflammation of, membranous deposit upon, or ulceration of, the 
fauces, and extensive swelling and induration of the lymphatic glands 
and subcutaneous tissues about the angles of the inferior jaw, and under 
the chin and throat. In connection with the throat-affection which de- 
velops itself in this wa} r , it is very common to have abundant purulent 
coryza, and often also otorrhoea. The symptoms assume, in fact, the 
features of the cases usually described under the title of scarlatina an- 
ginosa. As we shall, however, describe them directly in our account 
of the second set of grave cases, it is unnecessary to pursue the descrip- 
tion at the present moment. We will state, however, before proceeding 
further, that the anginose and general symptoms which occur in cases 
beginning with violent nervous phenomena, and especially with convul- 
sions, are nearly always of the most dangerous and malignant character, 
and usually end fatall}* in two, three, or four days after their appearance. 

The eruption . in this class of cases varies according to the violence of 
the attack. In the severest one that we saw, that which proved fatal in 
fifteen hours, no eruption whatever was perceived, and we only knew it 
to be scarlatina by the character of the other symptoms, and by the fact 
that the sister of the boy had been sick in the same house with the dis- 
ease for a week. In the case which terminated in twenty-four hours, the 
eruption showed itself in the form of scarlet patches about the face and 
upper parts of the body, twelve hours after the onset. In a third case 
the eruption was moderate, but perfectly well marked and general. In 
the other thirteen cases, which lasted, with one exception, not less than 
three days, the eruption was perfectly well marked. It covered the whole 
surface, was at first scarlet in color, soon ran into a deep red, and then 
became violet or purplish. The exceptional case was one which lasted 
thirty-six hours, and proved fatal in that time. In this also, the eruption 
was well marked and extensive. M. Gueretin (Arch, de Med., t. i, p. 292, 
1842), in his account of the acute malignant form which he witnessed, 
states that the eruption was nearly constant. In all our cases it occurred 
within twenty-four hours from the invasion, while in those of M. Gueretin, 
it appeared within twenty-four or forty-eight hours, or, as more frequently 
happened, not until the fourth or fifth da}^. 

If no favorable change takes place in these severe cases, and when 
they do not prove fatal at once, the patient grows weaker and weaker ; 
the delirium continues, or is replaced by coma; subsultus tendiuum, 
rigidity of the limbs, spasmodic twitchings or general convulsions, make 
their appearance; the eruption becomes more and more livid; the pulse 
grows smaller, more frequent, and irregular; the respiration is execs- 



682 SCARLET FEVER. 

sively embarrassed ; deglutition becomes impossible; and the patient dies 
in from three to seven or nine days. In some few instances, the chilcl 
struggles on for several weeks, and dies in a state of utter exhaustion, 
or, having a constitution of great powers of endurance, at last surmounts 
the disease and recovers. 

The invasion of grave cases is not alwa} T s, as we have stated above, so 
violent as in those which have just been described. In rather more than 
two-thirds (41) of the 57 grave cases that we have seen, the onset was 
less threatening than in the other third, though the symptoms were severe 
and dangerous in most of these also, and when not so at the very start, 
very soon assumed the serious characters which make it necessaiy to class 
the cases in which they occurred as grave. The chief difference between 
the s3 T mptoms that mark the onset of grave cases of this kind, and of 
those in which the symptoms are still more violent, which latter we have 
thus far been describing, lies in the character of the nervous phenomena 
— in the latter most severe, threatening, and dangerous, consisting of 
stupor, coma, or convulsions, and in the former, merely excessive agitation, 
restlessness, heaviness, or stupor. In one well-marked case of the kind 
now under consideration, the patient, a bo} T between seven and eight 
years old, was attacked in the evening with headache, fever, and vomiting. 
On the following morning a faint rash was perceptible, which, by the after- 
noon of that da} T , was distinct, though not very full. The case now rap- 
idly assumed unpleasant features. The pulse rose to 150. There was 
much drowsiness and delirium, and on the fourth daj' constant picking 
at the bed-clothes and at the fingers. In another case, in a boy between 
four and five years old, the first sign of sickness was slight languor after 
dinner, which was followed b} T fever in the evening, and the development 
in the course of the night of a scarlatinous rash. On the following day, 
there was some pain in the throat, with redness ; the pulse was 140, and 
the skin hot and dry; there were no nervous symptoms, except slight 
drowsiness. On the third day the pulse was 136, the rash was well out, 
and there were no unpleasant symptoms whatever. From this time, how- 
ever, the sjunptoms gradually grew worse; the throat-affection increasing, 
the cervical lymphatic glands becoming very much swelled, and the child 
growing more uneasy and restless, though retaining perfectly its intelli- 
gence. By the sixth day, the grave character of the case was fully de- 
veloped, the eruption being intense, and of a deep brick-red, verging 
towards a purple color. There was at the same time very great drowsi- 
ness, abundant discharges from the nasal passages of thick sero-mucous 
and purulent fluids, membranous exudation in the fauces, with gurgling 
and great difficulty in swallowing, and an utter loss of appetite. In a 
third case, a bo} T between one and two years old was a little fretful in the 
morning, and was seized in the evening with vomiting and fever, and 
very considerable restlessness. On the next day he was covered with a 
scarlet rash from head to foot, and the skin was fiery hot. The pulse was 
1G0, regular, not large. The child was very drowsy, dozing nearly all 
the time, but quite intelligent when aroused. The fauces were intensely 
red and rough, and the tonsils much swelled; there was very little exter- 



SYMPTOMS OF GRAVE CASES. 683 

nal swelling. On the third day he was still very drowsy, and, when roused, 
less observant than before, though he still recognized persons. The 
pulse was 168, small, difficult to count, very hard, and corded. The skin, 
especially that of the limbs, was scarlet, very hot, and dry; the cutaneous 
capillary circulation was good. After this the sj'inptoms grew rapidly 
worse ; the pulse continued at from 148 to 168 on the fourth and fifth 
days, and on the sixth rose to 172, at which it stood a few hours before 
death. On the fourth and fifth da}-s, he was still very heavy and drowsy, 
and so much so on the former as to take no notice whatever except when 
moved. On the fifth da} r , an abundant sero-mucous discharge took place 
from the nostrils ; the cervical lymphatic glands, which had begun to 
swell before, now increased in size ; there was some loud faucial gurgling, 
and the swallowing became difficult. On the morning of the sixth day, 
some of the symptoms improved so much as to flatter very greatly some 
of his attendants, who were unacquainted with the treacherous character 
of the disease. He roused up from his state of stupor, and noticed sev- 
eral things that were shown him, even taking them into his hand ; but 
the breathing continued bad, the lymphatic glands were swelling rapidly, 
and had alreadj T become very large, so that they formed great projections 
on either side of the neck. The pulse was 155, and small. In the mid- 
dle of the da} T the breathing became difficult, from the internal and ex- 
ternal swelling, and from the collection in the fauces of thick and viscid 
phlegm. The surface had now become pale. The tumefaction about the 
neck was immense. Down the front of the neck and along its sides to 
the clavicles, a kind of cedematous swelling of great size had come on, 
and was rapidly increasing. The pulse was 160, small, and feeble. The 
legs and arms were of a dark, congested tint. Deglutition was exces- 
sively difficult. In the evening the pulse was 172, and death took place 
just before midnight with slight convulsive movements. 

The mode of invasion is different, therefore, in different examples of 
the 'kind of grave cases now under consideration. In some it is even 
milder than in any of those that have just been detailed; and it is not 
until the third, fourth, or fifth day, or even later, that the severity of the 
attack shows itself fully and unmistakably. 

After the disease is once established, it will be found upon examina- 
tion, that the fauces are of a deeper red color, and that they are more 
swelled, than in mild cases. At the same time there is more difficulty 
and pain in deglutition ; these are complained of by older children, and 
are shown in those who are younger by their refusal to swallow, bj^ their 
crying upon making the attempt, and in some instances, especially at a 
later period of the sickness, by a positive inability to perforin the move- 
ment. In nearly all of these cases, false membrane is formed upon the 
mucous membrane of the throat. This is never, or very rarely, present 
on the first day of the attack. In most cases it is not found until the 
second or third, and often not before the fifth or sixth clay. MM. Rilliet 
and Barthez state that the}^ have known it not to appear until the tenth 
and eleventh days. It appears first in small, thin, whitish, yellowish, or 
ash-colored points or patches, on one or both tonsils, or on the soft 



684 SCARLET FEVER. 

palate only, where it remains limited, or from whence it extends to the 
pharynx, which it may cover in whole or in part. The patches are of 
variable thickness and consistence, and adhere sometimes very slightly, 
and sometimes with considerable tenacity to the mucous membrane be- 
neath. The}' maj T remain for a day, and then be thrown off not to be 
again produced; or they may form in several successive crops, until the 
case is terminated; or, as most frequently happens, the} T last three or 
four daj'S, or more, and are then detached. The mucous membrane upon 
which they are seated is found in various conditions. It may present the 
redness and swelling indicative of severe inflammation, or it maybe soft- 
ened, ulcerated, and, according to MM. Guersant and Blache, gangrenous, 
though, as a general rule, what have been supposed to be sloughs are in 
fact portions of altered false membrane. There is more or less fetor of 
the breath, sometimes amounting to a gangrenous odor, after the appear- 
ance of the pseudo-membrane. The severity of the sj'mptoms is in pro- 
portion to the extent and thickness of the false membrane. 

We have already seen that it is not uncommon to find ulcerations be- 
neath the false membranes. In other cases of this kind the throat-affec- 
tion assumes very great violence without the presence of an}- exudation 
whatever. In some the mucous membrane is of a deep red or even pur- 
plish hue, its consistence is softened, and it is swelled and covered with a 
layer of grayish or sanious pus. The tonsils are enlarged, infiltrated with 
pus, softened, and break down easily under the finger. In other cases, 
in addition to the redness and softening, ulcerations are present. These 
ma} r be superficial, amounting only to erosions, or they may extend through 
the mucous, and even submucous tissue, to the muscles beneath. They 
are seated generally in the pharynx, but ma}' exist also on the tonsils, 
and in some rare cases the} r extend into the larynx. In still more malig- 
nant attacks of the disease, we find evidences of gangrene of the pharynx. 
It is important to distinguish between those in which the pseudo-mem- 
brane becomes so changed as to assume the appearance of sloughs, and 
those in which the tissues of the pharynx are really gangrenous. The 
former constitute by far the greater number of the cases which have been 
generally regarded as instances of gangrene of the throat. That gan- 
grene of these tissues does actually occur in some few cases, is proved, 
however, by the evidence of Dr. Tweedie, who says (loc. cit., p. 650), that 
in malignant scarlatina "the membrane of the pharynx is sometimes of a 
dark, livid color, and occasionally in a sloughing state," and by that of 
MM. Guersant and Blache, who state that they met with several instances 
of gangrene of the pharynx in the pseudo-membranous angina which pre- 
vailed in 1841. 

An almost constant accompaniment of cases of this kind is inflamma- 
tion and swelling of the submaxillary lymphatic glands and surrounding 
cellular tissue. The tumefaction is generally confined at first to the glands 
beneath the jaw, which become painful to the touch. After a short time 
it extends to the parts behind the angle of the jaw, and beneath that 
bone, until at last the sides of the neck and the throat are largely dis- 
tended, so as to interfere with or even prevent in great measure, the 



SYMPTOMS OF GRAVE CASES. 685 

opening of the mouth, and by the pressure exerted on the internal parts 
of the throat, to add to the difficult} 7 - of deglutition which already exists. 
In some eases the pressure is so considerable as to embarrass the respi- 
ration of the child. This swelling has been generally supposed to depend 
on inflammation of the parotid glands ; but MM. Bretonneau, Guersant 
and Blache, and Rilliet and Barthez, all state that parotitis is of exceed- 
ingly rare occurrence, and that the swelling in question depends nearly 
always on the causes just described. The last-named writers state, more- 
over, that the tumefaction of the cellular tissue is often of the nature of 
active oedema. The swelling of the cervical lymphatic glands, and of the 
cellular tissue of the sides of the neck, and that under the throat and chin, 
seldom takes place to smy considerable extent, according to our experience, 
prior to the third or fourth da} r . During the first two or three days, the 
chief symptoms are the fever, the eruption, and the nervous phenomena, 
which latter consist, in this class of cases, of either excessive agitation 
and restlessness, or of drowsiness or stupor. Very often, after a child has 
seemed to be very ill for two, three, or four clays, from the violence of the 
febrile reaction and the severity of the nervous sj-mptoms, it will appear 
to improve very decidedly on the third or fourth day, and elevate greatly 
the hopes of those interested in it. It is just at this time, however, that 
the throat-affection is apt to set in severely ; and, moreover, it rarely fails 
to come in children who have presented violent symptoms during the first 
three days. The enlargement generally disappears, in favorable cases, 
in from three to twelve days, by resolution, while in others it terminates 
bj T suppuration of the glands and surrounding parts. 

In the form of the disease we are now considering, it is common to 
observe violent coryza, which may be either purulent or pseudo-membra- 
nous. It may appear from the very first, or not for several days after 
the eruption has commenced. The discharge is yellowish, granular, thin, 
very offensive, and highly acrid, so as to excoriate very much the upper 
lip. It often flows in surprising quantities, and generally continues up 
to the moment of death, or until all the symptoms have moderated. 

Otorrhoea is another s}miptom of this form. It generally occurs simul- 
taneously with coryza. The discharge is at first thin and watery, like 
that from the nostrils, but becomes gradually thicker as the case ad- 
vances. The quantity is extremely variable. In some cases we have 
known it to fill the meatus and concha of each ear, and then to flow out 
and make large stains upon the pillow, or to collect very rapidly after 
being wiped away. It is, like the coryza, an unfavorable symptom, as 
it is a mark of the grave form of the disease, and because, if the child 
recovers, it is very apt to result in deafness, which is but too often per- 
manent. 

These symptoms, coryza and otorrhoea, sometimes exist also in mild 
cases, but they do not then assume the peculiar characters which they 
present in grave cases. The discharges are much less abundant, and the 
mucus or pus is healthy, and scarcely offensive to the smell; they last but 
a short time, and are very rarely accompanied at the time or followed by 
more than a slight degree of deafness. 



686 SCARLET FEVER. 

The eruption is generally stated to appear later than in mild cases, 
and often to be less vivid and less extensive. It is also said to occupy 
only portions and not the whole of the body, to occur in irregular patches, 
or to appear and disappear alternately. This has not been the case in 
the instances which we have seen. In all but two of the forty-one, the 
eruption occurred early, generally within twenty-four hours from the on- 
set. It was of a deep brick-red or livid color, and covered the whole sur- 
face. In one of the exceptional cases it did not take place until the 
seventh da} T , when it appeared in patches on the wrists and knees. On 
the eighth day it extended to the rest of the extremities and abdomen, 
and on the ninth was general and of a rather dark hue. In the second 
exceptional case the eruption did not appear until the second day. It 
then came out over the whole trunk, and to a moderate extent upon the 
limbs also. In this, as in the previous one, it was dark in its tint. In 
three other cases it was quite moderate in amount, but general and well- 
marked. 

The general symptoms are more severe in grave than in mild cases. It 
sometimes happens that for one or two da} T s, or even longer, the case 
promises to be mild, but then suddenly assumes the threatening features 
of the form under consideration. The fever is usually intense, the pulse 
being full and strong, and rising very soon after the onset to 140, 150, or 
110; the skin is very hot and dry; there is more restlessness and irrita- 
bility than in the mild form, and after one, two, or three days, appears a 
strong disposition to delirium and stupor, not unfrequently merging into 
coma. The respiration is accelerated, and in many instances, owing to 
the throat-affection, labored and difficult. In most of the cases, a loud 
gurgling, which is very characteristic, is heard in the throat, particularly 
when the child is asleep or dozing. This depends in part upon the col- 
lection of viscid and tenacious secretions in the fauces, — which sometimes 
embarrass the respiration so much as to make it necessaiy to remove 
them with a mop, or by the operation of an emetic, — and in part upon 
the existence of the coiyza of which we have spoken. The coryza is a 
S3 T mptom of very serious consequence at all ages, but especially in young 
children. There is generally some cough, which may be frequent and 
troublesome, though not usually so unless there be a disposition to laiyn- 
geal complication. The voice is hoarse, guttural, and sometimes whis- 
pering. When the cough is very frequent, and still more, when it becomes 
hoarse and croupal, in connection with hoarse or whispering voice, or 
aphonia, there is great reason to fear the extension of the exudation 
into the larynx, which constitutes an almost necessarily fatal accident. 
The face is deeply flushed at first, and the expression anxious. If no 
improvement 'take place, the case assumes in four or five days, or even 
less, a still more threatening aspect. The pulse becomes very rapid and 
small ; the restlessness and delirium pass into drowsiness or coma ; the 
tongue becomes brown and dry ; the teeth are covered with sordes ; the 
lips are dry, cracked, and bleeding; diarrhoea is apt to occur; and the 
patient dies in from three to ten days, in a well-marked t} T phous con- 
dition. In other instances, on the contrary, the case runs on from week 



SYMPTOMS OF GRAVE CASES. 687 

to week, and at last, after an illness of four, five, or six weeks, the child 
either dies or recovers after all chances for life seem to have been lost. 

In order to show, in their natural connection, the different symptoms 
that have just been described, we will cite the following abstract of three 
of our cases. The first occurred in a boy between seven and eight years 
old. On the fourth day of the attack the pulse was at 150, and the fauces 
presented flakes of false membrane. The fauces were very much swelled, 
and deglutition became difficult; faucial gurgling came on, and the throat 
was filled with viscid and tenacious secretions. The nasal passages now 
became occluded by constant discharges, at first mucous and then muco- 
purulent, with admixture of membranous particles. From the fifth to the 
ninth day there was an excessive fetor from the nose and mouth. The 
lymphatic ganglions just beneath the ear swelled very greatly, so as to 
extend much beyond the line of the inferior maxilla. The tongue and 
lips became dry and cracked, the teeth were covered with sordes, and the 
angles of the eyelids inflamed and then ulcerated. On the. sixth, seventh, 
eighth, and ninth days, there were taken awajr from the mouth and throat 
of the child, with a mop, hard and most offensive masses of dried-up mu- 
cus and incrusted epithelium, enveloped in thick, gluey, dark colored 
mucus. These masses stuck to the fauces, tongue, and lips, so tenaciously, 
that the}^ could be removed onby by means of a mop, the boy himself being 
quite unable to detach them. On the seventh, eighth, and ninth days, 
though the cervical lymphatic glands were very much swelled, the patient 
was better. The pulse came clown gradually from 152 to 132, 128 and 
112, and the swallowing improved so much that the child could take 
liquids with less convulsive effort, and could drink continuously. The 
drowsiness diminished, and the delirium ceased. On the eighth day a 
slight erythematous redness appeared on the bridge of the nose, and ex- 
tended towards the malar bones. The skin of the face and eyelids became 
somewhat swollen and puffed by an cedematous effusion. On the ninth 
day the pulse was down to 104, and the skin was nearly natural as to 
temperature. The swelling was very great on both sides of the neck, and 
the glands on the right side were red on the surface, very hard, and quite 
painful. The swallowing was much easier for drinks, but as jet no solid, 
not even of the softest kind, could be taken. On the fourteenth day from 
the onset we opened a very large abscess on the left side of the neck, 
which discharged abundantly a healthy and laudable pus. On the fif- 
teenth day we opened a still larger abscess on the right side, and after 
this perfect recovery took place. 

In another example, which has been alluded to alread} 7- , occurring in a 
boy between four and five years old, the gravity of the case did not show 
itself clearly until the sixth day. On the evening of that day the pulse 
was 128, the skin very hot and dry, and there was an intense eruption of 
a brick-red color. There was, at the same time, great drowsiness, and 
utter loss of appetite. Deglutition was difficult, and there was a loud 
faucial gurgling during sleep. There was now also a considerable amount 
of membranous exudation in the fauces. During the seventh and eighth 
days, the boy continued very sick. He was drowsy, almost comatose; 



688 SCARLET FEVER. 

the eyes were half open and the conjunctiva minutely injected; there was 
an abundant coryza, the discharges being composed of offensive mucous 
and sero-mucous fluid, with an admixture of pus and of flocculent or 
grumous particles, the latter consisting evidently of broken-clown mem- 
branous exudation. There was no otorrhcea. The pulse rose from 120 
to 128. During the night of the seventh day the anginose affection was 
so severe that the child could swallow nothing from 10 p.m. to 3 a.m.; 
fluids poured into the mouth ran out again in part, and were in part re- 
turned through the nostrils. On the tenth day there was still no decided 
improvement, except that the pulse had fallen to 112. The coiyza con- 
tinued as before ; the fauces were covered thickly with whitish exudation ; 
the deglutition was a little easier. The drowsiness continued, as the 
child dozed nearly all the time, merely rousing from time to time to take 
drinks, and then, in spite of all solicitation, sinking into sleep again. 
The abdomen was tympanitic. The urine was rather free, more so than 
it had been before, and it was also clearer and of a lighter color. B} T the 
twelfth day there was a decided improvement; the pulse had fallen to 106, 
and the child was not quite so heavy. The act of swallowing was easier, 
and the fauces showed less of the plastic exudation, but they were still 
very much coated with tenacious mucus. On the thirteenth and four- 
teenth daj-s the patient continued to mend. The pulse fell to 98 and 92; 
the fauces had become clear of the exudation, and presented instead an 
excoriated and ulcerated appearance. The secretions into the fauces were 
less viscid and less copious. The coryza had diminished, and the dis- 
charges had become first muco-purulent and then mucous. The drowsi- 
ness had diminished, so that he waked spontaneously and began to ask 
for his to^ys. He now began to demand food, but refused to eat when 
things were brought to him. On the fifteenth day he was extremely 
irritable, screaming most violently for the slightest causes. On the six- 
teenth day the pulse was 92, and the skin nearly natural as to tempera- 
ture. He was now exceedingly emaciated and very weak. The orifices 
of the nasal passages were very much irritated and incrusted, but there 
was scarcely any coryza. The tongue was clean, pink in color, and moist, 
the thirst not too great, and there was a little appetite. The temper was 
improving. From this time forward the child improved steadily but 
slowly, so that he sat up for the first time on the twent3~-seventh day. He 
was as much emaciated at that time as after violent typhoid fever. 

The reader must not, however, suppose that all grave cases present 
throughout their whole course, symptoms as dangerous as those which 
marked the two examples that have just been detailed. In some, on the 
contrary, the symptoms, though of such a character as to deserve and re- 
quire the title of grave, are of a much milder kind. In order to make 
this part of our description of the disease as clear as may be, we will 
relate the following as an example of a grave case in which the symptoms, 
though severe, were neither malignant, nor at any one time very danger- 
ous to life. A girl between seven and eight years old was well at break- 
fast. In the course of the morning she complained of sore throat, and 
of not feeling well, and at 4 p.m., when we saw her, was quite feverish, 



SYMPTOMS OF GRAVE CASES. 689 

with a frequent pulse and hot skin, and showed already a well-marked 
but rather faint scarlet rash upon the trunk of the body, and about the 
elbows. On the following day the trunk and upper parts of the limbs 
were covered thickly with an intense eruption, of a bright scarlet color. 
The fauces were very red, somewhat roughened, and a good deal swelled. 
The only nervous symptom present was severe frontal headache. There 
was no unusual agitation, no drowsiness, and nothing like convulsive 
movement. On the evening of this day, the pulse had run up to 168, and 
it was rather full, but not hard. The skin was exceedingly hot and burn- 
ing; during the night there was great restlessness, and the child was 
wakeful and occasionally delirious. On the third clay the symptoms con- 
tinued much the same, except that the pulse was down in the morning 
to 152, that the rash had extended to the hands and feet, and that some 
small spots of whitish exudation were now visible on each tonsil. On the 
night of this day the fever again increased very much, and the child was 
again delirious. On the fourth clay the pulse was 148 ; the exudation had 
increased so much as to cover a good portion of both tonsils, and it had 
extended also in a slight degree to the posterior wall of the pharynx. 
There was now a considerable enlargement of the lymphatic glands situ- 
ated at the angle of the jaw on the left side, and a smaller one on the 
right side. Deglutition was somewhat painful, and a little difficult, but 
not seriously so. The case continued in much the same way until the ' 
seventh day, when the pulse had fallen to 132, and the eruption had faded 
very much on the trunk of the body, and to a considerable extent, upon 
the limbs also. The fauces now exhibited the false membrane over the 
whole of both tonsils, over the half-arches, the sides of the uvula, and 
upon the upper portion of the posterior wall of the pharynx. Instead of 
being whitish and clean-looking as at first, however, the false membranes 
now looked exactly like sloughing portions of the mucous membrane. 
They were of a dirty brown color, softened, and seemed to be detaching 
themselves like sloughs from the tissues beneath. On the ninth clay the 
patient was much better, the pulse having fallen to 116; the eruption had 
almost wholly disappeared ; the heat of skin was very much reduced ; the 
dark-colored portions of false membrane had disappeared from the fauces, 
leaving the mucous membrane beneath red, excoriated, and in parts 
ulcerated. On the thirteenth day, the child was convalescent, the pulse 
having fallen to 96, the heat of skin having disappeared, and the throat 
being nearly well. The appetite had returned, the temper was serene 
and cheerful, and the patient was, in fact, well, with the exception of 
weakness, and some remaining soreness of the throat. 

Laryngitis has been supposed by some persons to be of frequent occur- 
rence in the course of the disease, while others assert that it rarely, if 
ever, occurs. M. Bretonneau has never met with it. M. Ra} T er saj's he 
does not know that the exudation has ever been found in the larynx or 
trachea. Tweedie (Cyclop. Pract. Med., Art. Scarlatina, p. 640) states 
that in the dissections he has made he has not seen an instance of the 
membranous exudation extending into the larynx. That it does some- 
times occur, is proved nevertheless, beyond a doubt, by the evidence of 

44 



690 SCARLET FEVER. 

MM. Guersant and Blache, Rilliet and Barthez, and others, and by our 
own observation. MM. Rilliet and Barthez report three eases in which 
it was found in the larynx after death. These gentlemen state, however, 
that they have never observed the peculiar symptoms of croup. This 
does not accord with our own experience ; for in several cases that we 
have seen, all the peculiar symptoms of that malacty were present during 
life. The subject of one of these cases was a boy two j ears of age. A few 
days after the invasion of the disease, a severe and extensive pseudo-mem- 
branous angina was developed. This was soon followed by all the s} r mp- 
toms of croup, — hoarse cough, stridulous respiration, weak, feeble ciy, 
dvspnoea, and whispering voice, which lasted about five days, when the 
angina and croupal symptoms both diminished very much, and the child 
seemed in a fair way to recover : suddenly, however, extensive tumefac- 
tion of one side of the neck took place, and he died in twent} 7 -four hours. 
Unfortunately no examination could be made. In another case, in a 
child between six and seven years old, who had a most violent attack of 
the disease, severe croupal symptoms set in on the eighth day. They 
consisted of harsh, croupal cough, stridulous respiration, and great diffi- 
culty in swallowing, and the act of swallowing occasioned much harsh 
cough and strangling. The symptoms continued on the ninth clay, after 
which they moderated, and the child finally recovered entirety. In a 
third case, also a violent one, in a boy between eight and nine j^ears old, 
and in which general convulsions occurred on the first and second da} T s, 
the symptoms had improved a good deal on the third and fourth da} r . 
On the fifth day, he was not so well, being more restless and heavy, and 
having much difficulty in breathing, with some croupiness of sound. 
These sj^mptoms increased rapidly until they gave rise to most violent 
fits of suffocation, and caused a fatal termination on the sixth clay. In a 
fourth case, yi a child nine months old, death occurred on the thirteenth 
day from laryngitis, occurring in connection with membranous angina. 
The fatal termination was preceded by hard, dry, and croupal cough, 
stridulous respiration, and great difficulty of deglutition. In a fifth, in a 
child under a year old, croupal s} r mptoms made their appearance on the 
sixth day, the fauces being at that time covered with membranous exuda- 
tion, and the}' caused or assisted to cause a fatal termination on the 
eighth clay. In yet another case, the subject of which was between one 
and two j^ears old, a grave attack of scarlet fever was entirely recovered 
from. At the end of the second week the child was seized, owing to im- 
proper exposure in a cold house, against which the parents f had been 
properly warned, with anasarca. This also was recovered from, and 
again the parents were warned against improper exposure. On the very 
d?ij after our last visit, however, the child was taken clown stairs into a 
room with the windows open, and this on a mild day in the month of 
Februaiy. The child was seized now with diphtheritic angina, and died, 
after a few days, of croup. This was in the fourth week from the onset 
of the scarlet fever. In a seventh case, severe from the beginning, the 
patient recovered so as to be apparently out of clanger, but, owing to the 
room being very cold from the fact that it was large with wide rattling 



SEQUELS — DROPSY. 691 

windows down to the floor, and from the fire being too small, the child 
took cold, and, at the end of the third week, was seized with severe croup, 
which had many of the features of membranous croup, but which was, in 
all probability, spasmodic croup, dependent on ulcerative laryngitis. The 
case continued seven da} T s, during which time the patient was violently 
ill. but finally, after a most dangerous struggle, it ended favorably. 

The symptoms which indicate a disposition to implication of the laiynx 
are frequent, hoarse, and croupal cough, hoarse and whispering voice or 
cry. aphonia, and dj'spncea with stridulous respiration. 

The duration of grave cases of scarlet fever is very uncertain. In some 
the disease runs its course with frightful rapidity, destining life within 
a few hours or days. In others, though the S3anptoms of the early stage 
may seem to be as violent as in those where death occurs in a very short 
space of time, the patient either lingers for several days or two or three 
weeks, and then dies, worn out by the violence or malignancy of the at- 
tack, or else, after a most dangerous and apparently desperate illness, he 
finally struggles through and recovers. 

In the most violent of the grave cases, those which we described first 
as forming a separate group, 16 in number, of which 11 proved fatal, the 
duration in the fatal cases was between eighteen hours and six days. Of 
the 11, 1 proved fatal in eighteen hours, 1 in twenty-four hours, 1 in 
thirty-six hours, 4 in three da} T s, 1 in four days, 1 in five da} r s, and 2 in' 
six days. Of the 5 favorable cases, 1 lasted three weeks, 1 four weeks, 2 
six weeks, and 1 two months. 

Of the less violent of the grave cases, 41 in number, 14 died, and 27 re- 
covered. Of the 14 fatal cases, 1 died in four clays, 2 in five days, 2 in 
seven days, 3 in eight days, 1 in thirteen days, 1 in fourteen days, 1 in 
fifteen days, 2 in four weeks, and 1 in five weeks. Of the 27 favorable 
cases, the duration of the shortest was seven da} T s. The remainder lasted 
from twelve da}'S to six weeks, the most common period being between 
three and four weeks. 

Complications and Sequels. — Dropsy. — This is one of the most fre- 
quent and important sequelae of the disease. We have already remarked 
that in a considerable proportion of cases, the exact number apparently 
varying somewhat in different epidemics, the urine becomes albuminous 
during the stage of desquamation. This, however, is usually transitory, 
and probably depends partly on the condition of the blood itself, and 
partly on renal congestion. But in some cases, owing to one of the 
causes to be mentioned hereafter, the albuminuria persists, or if it has 
not been present or has disappeared, again makes its appearance; and 
the symptoms of acute nephritis develop themselves. Among these the 
most striking one is dropsy, and, indeed, so prominent is it, as to have 
alone attracted attention for a long time, and only to have been of late 
associated with a lesion of the kidneys. 

Certainly, in the vast majority of cases, when drops3 r appears as a sequel 
to scarlatina, the urine will be found to present all the characters present 
in acute Bright's disease ; and yet there are some high authorities (Simon, 
Becquerel, Philippe, Ra3'er) who assert that marked dropsy may occur 



692 SCARLET FEVER. 

without the slightest albuminuria. It is possible that some of these cases 
may be explicable by the fact that the urine has only been occasionally 
examined, and that albumen may have been temporarily present but have 
been overlooked ; but it at present seems undeniable, that, in some in- 
stances also, dropsy- ma}^ appear without any abnormal condition of the 
urine whatever. It is probable that, in these cases, the drops} T depends upon 
an anaemic state of the blood, developed during the course of the disease. 

The frequency with which drops}^ is developed, varies greatly in dif- 
ferent epidemics and in different forms of scarlatina. It occurred in a 
fifth of the cases of MM. Killiet and Barthez, and in 29 of the 263, or 
in about a ninth, of those observed by ourselves. It occurs generally 
in the course of the second or third week of the disease, and during 
the process of desquamation. It is thought to follow cases of moderate 
severity much more frequently than those of a grave character. Dr. 
Tweedie states that it has never been observed to succeed a malignant 
attack. This does not, however, accord with our own experience, since 
of the 29 examples that we have seen, 6 occurred in grave cases of the 
disease. Still it may be said on the whole, that the susceptibility to renal 
disease bears an inverse proportion to the activity and complete develop- 
ment of the symptoms of scarlatina. The effusion may attack any one of 
the cavities or the cellular tissue of the body, or all at once. The most com- 
mon form in which it appears is anasarca, after which the most frequent 
are, in the order in which they are mentioned, oedema of the lung, hydro- 
thorax, ascites, and lrydropericardium. 

The exciting cause of the drops} T is generally believed to be cold, con- 
tracted usually by exposure to air and moisture at too early a period. 
We have rarely known it to occur when the patient has been confined to 
the chamber or house until after the twenty-first da} T ; while, on the other 
hand, we have seen it follow immediately upon a ride in cool weather on 
the fourteenth day, the child having apparently been convalescent for 
several days before. We have known it to occur also when the child has 
been allowed to run through the house exposed to draughts from open 
doors and windows. 

We have been able, in a number of instances, to trace it directly and 
obviously to cold. Thus, in one very marked example, a boy between 
six and seven jears old had had a mild attack of the disease, and was 
so entirely recovered that we ceased our visits on the tenth da}', leav- 
ing strict injunctions with the mother as to the necessity of confining 
the child to the house for at least ten days longer. On the fourteenth 
day, he was allowed to sit for fifteen minutes, late in the afternoon of a 
cool April day, on the marble front-door step. He was seized that night 
with fever and vomiting, had anasarca next clay, and, during an illness of 
two weeks, had drops}- of the pericardium, effusion into the right pleural 
sac, ascites, and some signs of uraemia. In another case, a boy eleven 
years old had recovered entirely of a mild attack. He slept in a room 
heated by a stove. On the nineteenth day, the weather being cold, he 
got up early in the morning to light the fire which had gone out acci- 
dentally. He was attacked that day with bronchitis, and was, on the fol- 



SEQUELS — DKOPSY. 693 

lowing day, anasarcous. In another instance, anasarca was produced at 
the end of the third week, the child being quite well previously, by his 
being taken into a cold room to sleep. We could cite other instances of 
the same kind, but these are enough. It is sufficient to say that in a large 
majority of the cases that we have seen, it has manifestly and obviously 
followed improper exposure during the second or third week. In a few 
cases, however, it has come on without airy imprudence whatever, and we 
have been entirely unable to ascertain the cause. 

Xor can it }'et be asserted positively, that the action of cold will fre- 
quently cause drops3 T unless the urine have been previously albuminous : 
although it is undoubted that when albuminuria is present, any imprudent 
exposure will insure the occurrence of dropsy. 

We are in the habit now of always directing the mother or nurse to 
keep the patient confined to the chamber for four weeks from the onset 
of the disease, or, if it be allowed to run through the house, to take care 
to have it well clothed, and to keep the windows and doors carefully 
closed should the weather be cold or cloudy. This direction is one of 
the most important to be given in the course of the disease. It ought to 
be insisted upon in all and every case, occurring in the cool season of the 
year. 

The question was formerly much discussed, whether the condition of 
the kidney which accompanies scarlatinal dropsy was one of the forms 
of renal disease known as B right's disease. Dr. Johnson suggested 
that it was a peculiar affection of these organs, characterized by a des- 
quamation of the epithelium of the tubules, for which he proposed the 
name of desquamative nephritis. Recent observations have, however, 
shown that there is in reality nothing specific in the lesion, but that it is 
identical with other cases of renal catarrh or tubal nephritis, to use the 
excellent name bestowed by Dickinson, occurring from whatsoever cause. 
Indeed, it may be said that in almost 15 per cent, of all cases of chronic 
renal disease in children, the cause of the affection has been scarlatina, 
and the form of the lesion is that which we have above mentioned. 

Various causes have been assigned for the frequent development of 
tubal nephritis in the course of scarlatina. Thus it has been supposed 
that the affection of the kidneys resulted from inaction of the skin, owing 
to the intense congestion which attends the eruption ; but clinical ex- 
perience shows that it is precisely in the cases where the affection of the 
skin is most intense that the kidneys are least disposed to disease. It 
would rather appear that when the action of the virus is not fully deter- 
mined to the surface, there is violent congestion of the kidneys estab- 
lished, which, especially when the patient is exposed to the action of 
cold, may result in the development of tubal nephritis. 

Morbid Anatomy of the Kidneys. — When death occurs in the acute stage 
of the renal disease, the kidneys are found enlarged and very heavy. The 
surface is smooth and injected; on section, the organ drips with blood; 
the Malpighian bodies are congested, and appear as red dots ; and the 
vessels of the cortex and cones are gorged with blood. The tubules are 
distended with granular epithelium, granular matter, or fibrinous plugs. 



694 SCARLET FEVER. 

The cortex appears coarse-grained, and presents intermingled dots or 
streaks of red and buff color. In the more chronic form of the disease, 
the kidney is also much enlarged and very heavy; its surface smooth, and 
pale, or dotted with congested stellate vessels. The capsule is not thick- 
ened, and is readily removed. On section, very little blood escapes; the 
cones retain their pinkish or red color ; while the cortex is coarse-grained, 
thickened, and of a peculiar opaque white color. The Malpighian bodies 
may be distended, owing to obstruction to the escape of the blood. The 
principal lesion, however, is still found within the tubules, which are 
stuffed with epithelial cells, or with granular matter resulting from their 
disintegration ; occasionally, clear fibrinous plugs are also seen occupjdng 
their calibre. It frequently happens that the epithelium undergoes fatty 
degeneration, and when this is marked, the cortex acquires a 3 T ellowish 
tint. According to Dickinson, there is less tendency to this change in 
cases of tubal nephritis following scarlatina than after other causes ; a 
circumstance which he thinks may possibly account for the comparatively 
curable nature of scarlatinal drops}^. 

The dropsical symptoms usually show themselves in the third or fourth 
week of the disease, and are generally preceded for a few days by albu- 
minuria. In most of the cases that we have seen they occurred in the 
third week, but they sometimes appear at the end of the second, and 
sometimes not until the fourth week. In one case they showed themselves 
first on the thirtieth day, after the child had been exposed to too cool a 
temperature in an insufficiently warmed room. They occur, therefore, 
as a general rule, during the stage of desquamation. The attack is 
sometimes very sudden, but in most instances it is slow and gradual. 
The effusion is not commonly the first sj^mptom observed. On the con- 
trary, the dropsy is almost always preceded for one or two daj^s by the 
signs of a more or less considerable constitutional disturbance. The 
patient has usually passed safely through the eruptive stage of the fever, 
and has been considered for several days, sometimes for a week or ten 
da} T s, as convalescent, for, be it remarked, the dropsical affection is much 
more rare after grave than after mild cases. The child has perhaps 
been running about the house, or it has even been out, the parents sup- 
posing, unless warned by the physician, from the disappearance of the 
fever and other symptoms of illness, and from the return of appetite and 
ga3 r ety, that complete recoveiy has taken place. But, either after some 
exposure, or sometimes without any appreciable cause, the child be- 
comes drooping, languid, and irritable, or uneas}-, peevish, and restless. 
Simultaneously with or very soon after these symptoms, fever sets in ; 
the skin becomes dry and heated, and there is usually an elevation of the 
temperature to the extent of 4° or 5° ; the pulse is frequent and hard, or 
it is frequent and jerking ; the appetite is diminished or lost, and there is 
more or less thirst ; the bowels are generally constipated ; the urine is 
usually diminished ; and there is not unfrequentlv some nausea or vomit- 
ing, and complaints of headache. 

The symptoms which precede the appearance of the effusion are not 
always, however, so marked, while in other instances they are scarcely 



SEQUELS — DROPSY. 695 

noticeable, and yet the effusion may take place suddenly, and, affecting 
the subcutaneous cellular tissue and different internal organs simultane- 
ously, may cause a fatal termination with frightful rapidity. 

The effusion usually commences in the face, which becomes slightly 
swollen. The amount of the effusion is sometimes very slight, leaving us 
in doubt even whether there is really an}^ or not. The swelling is most 
marked about the eyelids, which look puffed, and it may be confined en- 
tirely to them, or, at least, it may be only in them that we can feel sure 
of its existence. From the face it extends to the hands and feet, and 
either remains limited to these parts, or spreads over the whole surface, 
and gradually or rapidly to the internal organs. The skin over the parts 
in which the effusion has taken place is firm, hard, and elastic to the 
touch ; it does not generally pit, at least not in the early stage, and it is 
of a dull white color. 

In very mild cases the constitutional disturbance is usually but slight, 
and the effusion may be so small in such instances, as to leave us in 
doubt as to the cause of the sickness. Generally, however, we have been 
able to determine the cause of the fever by a careful examination of the 
face, and particularly of the ej^elids, which look a little swelled and dis- 
tended, and by the presence of a slight pufliness or cushiony appearance 
of the backs of the hands and feet. In such cases the general symptoms 
usuall}' pass away after a few days ; the urinary secretion, which had 
been diminished in quantity and of a deeper color than natural, becomes 
again healthy ; the anasarca disappears, and the child returns to its ordi- 
naiy condition. In more severe cases the general symptoms are all more 
marked ; the anasarca is more extensive and the swelling more consider- 
able ; the child, if old enough to describe its sensations, complains of pain 
in the back, and the lumbar region is tender to the touch ; the urine ex- 
hibits much more marked changes in its character ; but still, unless some 
important internal cavity be attacked, the symptoms diminish after a 
week or ten days, and the child recovers gradually. In still more violent 
cases, the amount' of the effusion is very large indeed, the face is dis- 
figured by the swelling, the limbs are largely distended, the cellular tissue 
of the trunk of the body is infiltrated, the quantity of urine discharged is 
ver} r small or the secretion is arrested entirely for one or several days, 
and the fever is high. If the disease is not removed, the effusion may 
extend to the internal organs : to the lung, producing oedema of that 
organ, to the pleural sac, causing hydrothorax, to the pericardium, to the 
peritoneal cavity, or to the brain. Death may occur in these violent 
cases from asplryxia occasioned by oedema of the lung, by hydrothorax, 
or by the obstacle to the circulation caused by the presence of the effusion 
in the pericardium, from hydrocephalus, or the patient may sink into a 
comatose state like that which often precedes the fatal termination of 
Bright's disease in the adult, and due, like that, to uraemia. 

It sometimes happens, as was stated above, that death occurs with very 
great rapidity. MM. Guersant and Blache have known it to end fatally 
in twelve, fourteen, and thirty-six hours. In a case that came under our 
own observation in consultation, a child between one and two } T ears old, 



696 SCARLET FEVER. 

who had had a very mild attack of scarlet fever, was seized suddenly 
towards the end of the third week, after it was supposed to be quite well, 
and after exposure to draughts of cold air in the lower room of a small 
house, with vomiting, and shortly afterwards with convulsions and coma, 
which terminated fatally in thirty-six hours. In another case, in a boy 
between thirteen and fourteen years old, who had had a mild but well- 
marked attack, and who had convalesced, and been out of bed for a few 
daj's, fever with slight headache, and diminution of the urine, came on 
at the end of the second week. After two days of slight ailment, with- 
out any signs of anasarca, he suddenly, without aii}^ warning, fell into 
violent convulsions, which were repeated frequently, with lulls of imper- 
fect consciousness, for a few hours. After twelve hours he became com- 
pletely comatose, with occasional convulsive seizures, and died at the end 
of eight hours more. 

According to Gee (loc. czY.), uraemic convulsions and coma are not fre- 
quent in the course of scarlatinal dropsy, nor are the} 7 " of such fatal im- 
port as in acute Bright's disease in the adult. 

The symptoms which mark the occurrence of internal effusion will 
depend of course upon the part attacked. In one case the}^ will be those 
of cedema of the lung, in another those of hydrothorax, and in another 
those of hydropericardinm or ascites. 

Urine. — The particular condition of the urinary function is next to be 
described. It has already been stated that the amount of urine secreted 
is less than natural during the early period of the dropsical attack. But, 
while this is true, it ought to be observed that the patient often voids the 
secretion more frequently than usual. There is in fact micturition, a 
symptom occasioned no doubt by the irritating character of the urine, 
which causes the bladder to contract and expel that fluid so soon as even 
a small quantity collects. The diminution in the amount of the secretion 
is usually a veiy marked symptom. It is sometimes almost or even en- 
tirely suppressed for a considerable period. In one case that occurred 
to one of ourselves, in a boy between one and two years old, there was no 
discharge whatever for a period of thnMTy-six hours. During this time 
there was no distension of the bladder, as we ascertained this point hy 
careful palpation and percussion. In another case, which occurred in a 
girl between three and four 3'ears old, and who was nursed by the grand- 
mother, one of the most accurate, reliable, and experienced nurses in the 
city, we were assured that there was no discharge whatever of urine for 
five days in succession. During this suppression there was no accumula- 
tion in the bladder. On the contrary, the hypogastric region was flat, 
depressible, and sonorous on percussion. The patient was very ill during 
all this time. She was feverish and passed nearly the whole time in a 
semi-comatose state, but could be roused with much effort, so as to show 
some intelligence ; she rejected b}' vomiting almost everything that was 
given her, and complained when aroused of severe headache. She had 
no convulsions nor anj r convulsive movements, and finally recovered as 
the kidneys regained gradually their secretory function. In many other 
cases that have come under our observation, especially those which we 



SEQUELiE — DEOPSY — CONDITION OF THE URINE. 697 

have seen in latter } T ears, when we have watched this symptom more care- 
fully, the diminution of the urine has been very great, so much so as to 
constitute a most marked and reliable symptom. 

In mild cases, when the diminution is not very marked, the urine is of 
a deeper color than natural, but retains its transparency when first voided. 
It is apt, however, to become turbid on cooling, and to deposit a more or 
less abundant precipitate of urates. Its reaction is acid ; its specific 
gravity increased in proportion to the concentration ; and urea and the 
chlorides are much diminished. Albumen is present, and microscopic 
examination shows epithelial or lryaline casts of the renal tubules, renal 
epithelium, and blood globules. In more severe cases, the urine is very 
much diminished in quantity, the color is either a very dark red, or has a 
blackish or brownish tint, or is like smoke or soot ; the specific gravity 
is very high ; the amount of albumen large, and the precipitate contains 
many casts and blood globules, mixed with abundant urates. 

The amounts of albumen and blood bear no definite relation to each 
other ; in some cases, the albumen may be abundant without any blood 
being present ; while in other cases, with a large precipitate of blood 
globules, the urine ma} T contain but a slight trace of albumen. 

Basham calls attention to the occasional development of a bluish-green, 
and subsequent!}- greenish-black color, on the addition of nitric acid to 
the heated urine, as a sign of very grave augury, being associated with 
extensive and advanced renal disease. 

The duration of this stage of diminution of urine varies greatly in 
different instances, and is to a certain extent indicative of the future 
progress of the case. It is succeeded by a stage 1 in which the urine be- 
comes abundant, even exceeding the normal amount, the specific gravity 
falls, and the urea and chlorides return to the normal figure, but albu- 
men is still present, the smoky color is apt to persist, and the precipitate 
which forms on standing contains renal epithelium, blood globules, and 
granular or epithelial casts. 

In favorable cases, the smokiness and albumen now gradually disappear, 
the urine often continuing for a little while to be secreted in excessive 
quantity; but in other cases, and unfortunately the} r are but too frequent, 
the albumen persists, and the urine assumes the characters indicative of 
chronic Bright's disease. 

The form which the dropsy takes varies greatly in different cases, 
and seems to depend on inappreciable causes. Of the 29 cases that we 
have met with, anasarca alone was present in 22. In 1, there was exten- 
sive anasarca, hydrothorax of the right side, hydropericarclium, and 
ascites. In 5, grave cerebral symptoms, probably urasmic in character, 
were present ; and in 4 of these anasarca also existed. In 1 there were 
also hydrocephaloid symptoms, but of much less violent form. 

Recent researches have established the fact that most of the cases 
former!}' regarded as hydrocephalus are in reality due to the poisoned 
state of the blood, the so-called uraemia, so familiar to all, that it is merely 
necessary to allude to it in this place. 

The degree of danger to be apprehended from this dropsical complication 



SCARLET FEVER. 

depends upon the form which it assumes. M. Cazenave (loc. cit., p. 52) 
says that there is no danger from it so long as it remains confined to the 
subcutaneous cellular tissue ; and this is probably true. When, however, 
it attacks the serous cavities, or becomes associated with cerebral symp- 
toms, due to the retention of urea and other excrementitious matters in 
the system, it is exceedingly dangerous. Dr. Wood (Pract. of Med., vol. 
i, p. 403) says that he has seen but one fatal case of drops}^, and in that 
the heart was diseased. Of the 29 cases that we have had under charge, 
6 were fatal. Of the 22 cases in which the effusion was anasarcous alone, 
but 1 was fatal. All of the 5 in which well-marked hydrocephaloid symp- 
toms, due to uraemia, occurred in connection with anasarca, ended fatally. 
In one other case, which ended favorably, there were mild ursemic S3anp- 
toms present. In the case above adverted to, in which Iryclrothorax, 
hydropericardium, and ascites were added to the anasarca, the patient 
recovered after a long and severe illness. 

In addition to the cases of dropsy and uraemia just referred to, and which 
all occurred in our own practice, we have seen two examples of scarlati- 
nous dropsy with ursemic symptoms in consultation, one of which came 
on very suddenly in a young child, and proved fatal in thirty-six hours, 
while the other terminated favorably after a severe illness of nearly two 
weeks. In the latter case, the patient, a girl, between three and four 
years old, was in a semi-comatose state for a week, with fever, excessive 
irritability of the stomach, and complaints of headache. For a period of 
five days the urine was entirely suppressed, not a drop having been voided 
during all that time, at least with the knowledge of the nurse, who was a 
most accurate and competent person. In a third case, seen in consulta- 
tion, the child died after ten days' violent illness, with ascites, extensive 
hydrothorax, and dropsy of the pericardium. Lastly, in a fourth case, 
also seen in consultation, the patient, an infant in its second year, after 
having had anasarca for a few days, became drowsy, had frequent vomit- 
ing and heat of head, but recovered under the use of active counter- 
irritation over the back and diuretics. It would seem to be much more 
dangerous in the Parisian hospitals than in private practice in this 
country, since MM. Ckiersant and Blache speak of having seen it prove 
fatal in twelve, fourteen, and thirty-six hours, after one or two weeks, or 
even two or three months ; and MM. Rilliet and Barthez refer to it as 
often proving fatal. 

Diarrhoea is not an uncommon accident in the disease. It generally 
depends- on simple functional derangement of the bowels. In some cases, 
however, it is so severe or long-continued as to constitute a serious com- 
plication. Under these circumstances, it depends on follicular entero- 
colitis, slight erythematous inflammation, or simple softening of the in- 
testinal mucous membrane. , 

In some cases, chronic angina remains after the subsidence of the dis- 
ease ; so, too, coryza may persist, even taking the form of ozoena. 

Otorrhoea is a not infrequent sequel, and when following angina, and 
due to the extension of inflammation up the Eustachian tube, may be as- 



SEQUELS — ANATOMICAL LESIONS. 699 

sociated with permanent deafness, necrosis of the temporal bone, facial 
palsy, and even abscess of the brain. 

Occasionally during the desquamative period, a painful swelling of the 
joints appears, attended with a renewal of the fever and, frequently, with 
sweating. This form of rheumatism is in all probability connected with 
the imperfect excretion of some excrementitions substance, owing to the 
state of the various emunctories. In rather rare cases, the inflammation 
of the joint runs on to fatal suppuration. 

Bronchitis cmd pneumonia are rare. Inflammation of the serous mem- 
branes is more common, occasioning in some cases the dropsical effusions 
which have already been treated of. It is in most cases connected either 
with renal disease or with the form of rheumatism above described. The 
pleura is more frequently affected than an} 7 other of the serous membranes ; 
and not rarely the effusion becomes purulent. 

Inflammation of the investing or lining- membrane of the heart also 
occasionally occurs. Thus, of 39 cases of enclo- or pericarditis mentioned 
by Dr. West, 6 could be traced to an attack of scarlatina. 

Peritonitis is much more rare, and the effusion here also is especially 
apt to be purulent. 

Scarlatina may be coincident with variola or measles. We have never 
seen it in connection with the former, but in two cases which came under 
our observation it was complicated with measles. 

Diphtheria has also been observed not very rarely, usually appearing 
during convalescence. In a considerable number of cases, scarlatina has 
been noticed in the course of typhoid fever. 

In some rare cases, as in the one detailed under the head of prognosis, 
more or less complete paralysis ensues during the convalescence from 
scarlatina. 

Tuberculosis is not nearly so apt to be developed after scarlatina as 
after either rubeola or typhoid fever. 

Anatomical Lesions. — The eruption sometimes disappears entirely 
after death, and on other occasions assumes a deep livid or purple appear- 
ance. The epidermis is generally loosened upon the integument, so as to 
be peeled off with great facility. The most important lesions, and those 
which seem to belong to the nature of the disease independent of compli- 
cations, are the altered condition of the blood, and congestions of differ- 
ent parts of the body, particularly the brain, serous membranes, kidneys, 
spleen, glands of Peyer, and intestinal follicles. We have already alluded 
to the fact that, even when the cerebral symptoms have been most severe, 
and we might expect to find evidences of violent inflammation of the 
brain, nothing is observed after death, in the majority of cases, but con- 
gestion of the large veins and sinuses of the brain, of the pia mater, or 
of the cerebral substance. There is rarely any unnatural amount of serous 
effusion into the ventricles, or meshes of the pia mater ; and it is evident 
that the symptoms have been due entirely to the vitiated condition of 
the blood. Nevertheless, effusions within the cranium may exist, in 
some few cases, as has been already stated in the remarks upon hydro- 
cephalus. 



700 SCARLET EEVER. 

The respiratory organs are usually healthy, with the exception of con- 
gestion and serous engorgement. 

According to the researches of Fenwick, Fox, and Murchison, it appears 
that the entire gastro-intestinal mucous membrane is affected in many 
cases of this disease. There is congestion of the sub-epithelial layers, 
with excessive formation and subsequent desquamation of the epithelium. 
The gastric tubules are greatly distended and obstructed by cells mixed 
with granular and fatty matters, and casts of their calibre are frequently 
found in the matters vomited or in the contents of the stomach after 
death. 

The condition of the skin resembles this closely, the rete mucosum 
being thickened, with a formation of numerous round nucleated cells, and 
the sudoriferous glands being often obstructed bj T the rapidly formed cells. 

The glands of Brunner and Peyer are not unfrequently enlarged, and 
they are sometimes reddened or softened. In a smaller number of cases 
the mesenteric glands are slightly inflamed and increased in size, and the 
spleen is redder than usual and softened. These lesions have no neces- 
saiy relation to the form of the disease, since they are often absent in 
typhoid cases, and present in those of a different type. 

The kidneys are healtlrv, with the exception of some degree of conges- 
tion, unless the case has been complicated with drops % y. Under these 
circumstances they usually present the characteristic lesions of tubal 
nephritis, which we have already described. 

The heart occasionally presents the results of inflammation of its lining 
or investing membrane ; and in some cases its cavities contain firm white 
ante-mortem clots. 

The blood exhibits very different appearances in different cases. It is 
viscid or serous, dark-colored or light, and fluid or coagulated, the clots 
being of variable color and density. The proportion of its constituent 
elements is changed. The fibrin maintains its usual relation to the mass 
of the fluid (3 parts in 1000), or it is very slightly augmented, while the 
quanthVv of the globules is increased to 136 or 146 parts, according to M. 
Andral, instead of 127, in 1000 parts. This increase in the proportion of 
fibrin ma} 7 be in part the cause of the fibrinous depositions which occa- 
sionally are found in the cavities of the heart, and appear to have been 
instrumental in causing death. 

Diagnosis. — It is impossible to distinguish scarlatina from the other 
eruptive fevers by the symptoms which precede the eruption. The only 
signs upon which a diagnosis at that time might be grounded, are great 
frequency of pulse, which is characteristic of this disease, some soreness 
or redness of the fauces, and the prevalence of the disease in the com- 
munity. But these are all exceedingly fallacious, and the physician 
should be content to wait for the eruption before he ventures to speak 
with certainty. After the eruption has come out it can scarcely be mis- 
taken for an} T thing else, except it be roseola. 

From measles it may be distinguished b} r the differences in the pro- 
dromes, course, and eruption of the two affections. The prodromic stage 
of scarlatina rarely lasts more than twenty-four hours, and is very often 



DIAGNOSIS. 701 

much less; that of measles, on the contrary, is almost always from three 
to four days: in scarlatina the rash appears suddenly aud often spreads 
over the whole body in a single day; in measles it appears on the face first 
and extends gradually to the rest of the surface, seldom reaching the hands 
and feet before the end of the second day; the eruption of measles occurs 
first in distinct papules, which coalesce and form patches of an irregular 
ere?eentic shape, while that of scarlatina is in the form of innumerable 
minute dots or punctuations, placed so closely together as to give to large 
portions of the surface a uniform color, like that produced by blushing. 
The color of the two eruptions is different, that of measles being dark 
like raspberry juice, and that of scarlatina of a more or less bright scarlet 
tint. The presence of catarrhal symptoms in measles and their absence 
in scarlet fever ; the absence of angina in the former disease, or its very 
slight character, and the severity of the throat-affection in scarlatina; and 
lastly, the greater severity of the febrile symptoms, particularly the fre- 
quency of the pulse and the heat of skin in scarlatina, are other points 
of difference which will assist in making the diagnosis, rarely, it seems 
to me, difficult, still more certain. A very great frequency of the pulse 
is one of the most unfailing s3 T mptoms of the early stage of scarlet fever. 
It almost alwa}'s runs up to 140, 150, or 160, in young children, within the 
first twelve or twenty-four hours, and to 120, 130, 140, or higher, in those 
who are older. Nevertheless, this, like all other symptoms, is sometimes 
wanting. We have lately seen a boy, between five and six years old, 
with a marked but very safe attack of the disease, whose pulse ranged 
between 80 and 90 throughout the sickness. This was, however, the only 
case we have ever met with, in which the pulse remained so little disturbed. 

It is sometimes very difficult to determine with precision between 
roseola and scarlet fever. B3' the eruption alone, we believe it to be often 
impossible. We have seen quite a number of cases in which the erup- 
tion of roseola resembled so closely that of scarlet fever, that we should 
have been obliged to confess our inability to make the distinction had it 
not been for the other symptoms, and particularly the frequency of the 
circulation, the heat of the skin, and the throat-symptoms. The most 
important differential symptoms are the tint of the eruption, which in 
roseola is rose-colored, in scarlet fever bright-red or scarlet; the charac- 
ters of the patches of eruption, which are more regular in shape, but of 
much smaller size in roseola than in scarlet fever ; the absence or very 
slight degree of anginose inflammation in roseola; and, what is decidedly 
the most important of all, the very much slighter degree of febrile reac- 
tion in roseola, in which the pulse, instead of being doubled in frequency 
as it is in scarlet fever, is scarcely above its natural rate, and in which 
the heat of skin is but little above the standard of health. Moreover, 
roseola is generally of shorter duration, and is a milder affection, and 
therefore accompanied by far less fever and general disturbance of the 
constitution. 

Diphtheria occasionally resembles scarlatina to so great an extent, as 
to have even led some observers to consider them identical. Thus, there 
is in diphtheria a pseudo-membranous angina, with swelling of the cervical 



702 SCARLET FEVER. 

glands, and at times albuminuria, and even an erythematous rash. "We 
have elsewhere (see article on diphtheria) given at length the differential 
diagnosis between these affections, and will here merely call attention to 
the fact that the rash is a rare exception in diphtheria, and is a mere 
uniform erythematous redness ; that even when albuminuria is present, 
the urine does not present the other characters noted in scarlatina ; and 
that the condition of the fauces in the two diseases is somewhat differ- 
ent. There is, further, a wide difference in the sequelae of the disease; 
and, finally, they do not exercise any protective power whatsoever against 
each other. 

There is a form of disease known as rubeola notha, epidemic roseola, 
rosalia (Richardson), in which there are some of the symptoms of both 
measles and scarlatina; the eruption appearing on the second or third 
day, at first resembling that of measles, but becoming soon more like 
that of scarlatina. Coiyza and angina ma}^ both be present, and there is 
subsequent desquamation. Some authorities regard this as a union of 
the poisons of measles and scarlatina, while others consider it a separate 
disease, because epidemics of it occur when neither measles nor scarla- 
tina are prevailing. Previous attacks of these latter do not protect 
against it. In an extensive epidemic, of which we saw many cases in the 
practice of Dr. Gr. Pepper, of this city, which appeared to be of this na- 
ture, not a single case was followed by any of the sequelae of either measles 
or scarlatina. 

Prognosis. — It is impossible to obtain a useful average mortality of 
scarlet fever, since the disease varies so greatly in different epidemics, 
and under different hygienic conditions, that the results obtained during 
one period are inapplicable to cases observed at another. This is proved 
by the experience of almost every physician, and by the evidence of many 
writers. It is proved, also, by the following facts : M. Gueretin (loc. tit., 
p. 283) states that the mortality in the epidemic observed hy him was 
about 1 in 12; of 99 cases, 8 died. MM. Rilliet and Barthez lost a little 
more than half their cases; of 87, the total, 46 were fatal. These cases, 
let it be remarked, however, occurred in the Hospital for Children in Paris, 
which will account for the heavy fatality. The degree, however, to which 
the mortality may vary in the same place and under the same plan of 
treatment, is shown by the fact, mentioned by Hillier, that in the course 
of eleven years the annual mortality from scarlet fever in the London 
Pever Hospital, varied from 2.5 per cent, to 16.5 per cent.; and in the 
Hospital for Sick Children in London, from 9 to 31 per cent. Of the 263 
cases that we have observed, 28, or rather more than one-ninth, were fatal. 
Of the 263 cases, 104 occurred between 1849 and 1853, and in those the 
mortalit}" was much smaller than in those which occurred prior to that 
year. Of 104, 11 were fatal, or about one in nine and a half. Seventy- 
eight cases occurred between 1853 and the spring of 1857. Of these 78, 
only 4, or one in twelve, were fatal. Of the 81 cases observed previous 
to 1849, 13, or about 1 in 6, proved fatal. The mortality met with by 
ourselves in private practice, has greatly varied, therefore, in different 
series of years. In one series it was 1 in 6, in another 1 in 9£, and in a 



PROGNOSIS. 703 

third 1 in 12. Lastly, to show the influence of the epidemic tj^pe upon 
the mortality still more clearly, we may state that of the last series of 
cases observed, TS in number, 43 occurred during the epidemic which 
lasted from the summer of 1856 to the spring of 185?, and of these only 
3, or 1 in 11, died. 

The prognosis must be based, therefore, in part on the character of the 
epidemic prevailing at the time. It must depend also on the nature of 
the case. Mild and regular cases are rarely fatal. Of 206 mild cases that 
have been under our care, only three proved fatal. One of these would 
probably not have so terminated had it not been for the imprudence of 
the nurse. This was, in fact, the case of a young child who had recovered 
from the eruptive stage of the disease, but whom the nurse carried out 
of the room in the second week, notwithstanding express directions given 
her to the contrary. The child took cold and was seized with catarrh 
and slight anasarca; on the fifteenth day ursemic symptoms set in, and 
he died on the seventeenth day, comatose, and with convulsive move- 
ments of different parts of the bod} r . The second case was that of the 
boy thirteen years old, already described, who died with sudden hydro- 
cephaloid S3mptoms, at the end of the second week. The third fatal case 
occurred in a girl between eight and nine j r ears old, who died suddenly 
at the end of six weeks. The patient had convalesced sufficiently to have 
been out several times, but remained very hydrsemic and weak. After 
being much fatigued one afternoon by playing with some little friends, 
she was seized next day with vomiting, and soon after with great diffi- 
culty of breathing and extremely rapid and feeble action of the heart. 
These s}'mptonis increased on the following day. The dyspnoea was 
most severe, and was attended with cyanotic color of the hands and face, 
and with cold colliquative sweats. The lungs were free, there was no 
cough, and auscultation revealed no pericardial lesion. Death occurred 
suddenly at the end of a day and a half. No post-mortem was made, 
owing to circumstances that could not be controlled. Our own opinion 
was, and is, that the death was caused by a coagulum in the heart. 

Grave cases of scarlet fever are always, on the contrary, exceedingly 
dangerous: thus of 57 cases of this kind that we have had under charge, 
25, or nearly a half, were fatal. In order to render the description of the 
S3 T mptoms of this class of cases more clear, we divided them into two 
groups ; one, in which the onset of the disease is instantaneous and most 
violent, being characterized by excessive disturbance of the nervous sys- 
tem, taking the form usually of convulsions, but sometimes only of pro- 
found coma ; and a second, in which the S3<mptoms of the onset, though 
severe enough usually from the first to mark the character of the case as 
grave, are less violent than in the first group, and especially not marked 
by the occurrence of convulsive phenomena. Of 16 cases belonging to the 
first group, 11 died ; while of 41 belonging to the second, 14 died. Violent 
nervous symptoms occurring early in scarlet fever augur, therefore, great 
danger to the patient, since of 16 cases in which the}' were present, 11 
died, whilst of 41 in which they were more moderate, though still marked 
and severe, only 14 died. 



704 SCARLET FEVER. 

The character of the nervous symptoms is, therefore, all-important in 
the determination of the prognosis, as the probable termination of the 
case is to be foretold more certainly by a just appreciation of these par- 
ticular phenomena of the disease, than by any other means. Excessive 
jactitation or irritability, delirium, coma, and the hydrocephalic cries, are 
all unfavorable symptoms, but not in the same degree as are those con- 
nected with the locomotive apparatus. MM. Rilliet and Barthez state 
that the}' have seen recoveries take place in cases in which the intelligence 
of the patient had been very much disordered, while of those who, u dur- 
ing the first fifteen days of scarlatina, were taken with convulsions, con- 
vulsive movements, contractions, in a word, any symptoms affecting the 
locomotive apparatus, all, without exception, died." This does not accord 
exactly with our own experience, though nearly enough so to show how 
exceedingly dangerous are the symptoms just enumerated when they 
occur earlj' in the disease. General convulsions occurred on the first 
da}' of the disease in 7 of the 57 grave cases observed by ourselves, and 
of these not one terminated fortunately ; in four they occurred on the 
second day, and of these three recovered and one died ; in one they oc- 
curred on the ninth day, and this patient also recovered ; in another case 
there were no general convulsions, but on the first day there were auto- 
matic motions, with involuntary extensor motions of the arms and fingers, 
and on the second day strabismus, with a continuation of the automatic 
motions. This case proved fatal. Of the 13 cases, therefore, in which 
marked disturbances of the muscular system occurred, only 4 ended fa- 
vorably. Of 8 subjects in which the convulsive phenomena occurred on 
the first day of the disease not one escaped. Of 5 subjects in whom these 
symptoms appeared on or after the second day, 4 escaped. One of the 
favorable cases occurred in a boy seven years old, who had a general con- 
vulsion, lasting several minutes, on the second day of the attack ; this 
was followed by delirium and coma alternately, but no return of the con- 
vulsions. The case was a most violent one, and lasted six weeks, leaving 
the child at the termination very deaf, but otherwise in good health. 
The second case occurred in a child five months old. The convulsive 
symptoms appeared on the ninth day, and consisted of strabismus, spas- 
modic retraction of the head, and occasional slight spasms of the limbs. 
They alternated with coma, and disappeared on the tenth day, until the 
seventeenth and eighteenth, when the strabismus reappeared. The child 
recovered perfectly. The third was that of a very healthy and vigorous 
boy between eight and nine years old, who, on the second day of an attack 
which had begun like a severe cholera morbus, had, twice, fits of insen- 
sibility, with stiffening of the extensor muscles of the fingers, rigid con- 
tractions of the flexors of the arms, and spasms of the eyeballs. This 
case proved afterwards very violent, so that the patient nearly died on the 
fifth day, with asphyctic symptoms caused by very great swelling of the 
tonsils and fauces, and enormous enlargement of the external cervical 
lymphatic glands, complicated moreover with extensive acute oedema 
about the chin and front of the neck. These symptoms were followed 
again by diphtheritic deposit covering the whole of the pharynx. He 



PROGNOSIS. 705 

finally, however, recovered perfectly. The fourth case was that of a boy 
between five and six years old, who, on the second day, had an attack of 
general convulsions, which were repeated frequently on the third day. 
This patient continued very ill for several days, and when, at last, he 
began to improve somewhat in the middle of the second week, it was 
found that he had lost entirely the power of speech, and all control over 
nearly the whole of the locomotive apparatus of the body. He could 
neither lift his head nor turn it ; the legs were immovable ; the hands 
were perfectly helpless. The only motion that remained was a jerking, 
apparently almost automatic, movement of the arms upon the shoulders, 
and the forearms upon the arms. But even these were most irregular, 
and badly co-ordinated. He was very much in the condition of a new- 
born child. It was very difficult to ascertain what the condition of his 
senses was ; but after a short time we were able to satisfy ourselves that 
he saw and heard, and only after manj^ weeks was he able to hold a very 
light object in his fingers, then to move his head from side to side, and at 
a still later period to hold it up. At the end of about two months, he 
could sit in a chair when once placed in it, but could not sit on the floor 
unsupported. At the end of three months he was learning to walk by 
being held up b} T the arms. He had never spoken a word. The only ap- 
proach to anything like articulation was his ability to hum a low gentle 
musical note; his intellectual faculties, as exhibited by signs, had re- 
gained their natural condition at this time. At the end of ten months, 
he could speak intelligiblv some three or four words. The fifth case was 
that of a male infant, nine months old, who, on the second day, had 
severe general convulsions, followed by very deep drowsiness. The erup- 
tion became intense, and on the third day the convulsive symptoms re- 
curred from time to time, but with less violence. On the fourth day he 
seemed somewhat better, but on the fifth very severe anginose symptoms 
set in, and he died. 

Again, in 18 of the 57 grave cases, severe and more or less prolonged 
delirium or coma occurred, and of these 12 died. We may conclude, 
therefore, that convulsive symptoms appearing early in scarlet fever in- 
dicate a highly dangerous and, in all probability, a fatal attack; while 
severe, and especially prolonged delirium or coma, are also extremely 
unfavorable symptoms, but somewhat less so than are those of a convul- 
sive character. 

Other unfavorable symptoms are: extremely frequent or very violent 
pulse ; intense heat or unnatural coolness of the skin ; persistently elevated 
temperature after deflorescence ; deficiency or sudden disappearance of the 1 
eruption ; a livid or purple tint of the eruption ; slow and imperfect capil- 
lary circulation, as ascertained by pressure ; the appearance of petechia?, 
ecchymoses, or hemorrhages ; violent vomiting and colliquative diarrhoea; 
great violence of the throat-affection, whether from tumefaction, great 
abundance of pseudo-membranous exudation, or disposition to ulceration 
and sloughing; and lastly, severe coryza or otorrhcea. A disposition to 
a typhoid state, indicated by dulness of the intelligence, dusky hue of 

45 



706 SCARLET FEVER. 

the skin, frequent and feeble pulse, dry, brown tongue, sordes on the teeth, 
meteorism, and disposition to diarrhoea, is always dangerous. 

When, on the contrary, the fever is moderate, the cerebral symptoms 
absent or very slight, and the eruption regular, and of a bright tint; 
when there is no disposition to typhoid symptoms; when the throat-affec- 
tion is mild, and the disease pursues a regular, uniform course, we have 
every reason to expect a favorable termination in a large majority of the 
cases. 

In addition to these remarks it may be said that neither age, sex, nor 
social position influence the prognosis. A delicate constitution does not 
seem to predispose to a violent attack of scarlatina, and indeed, many of 
the most malignant cases occur in very robust children ; but, on the other 
hand, it has been noticed that in certain families there exists a strong 
tendency for the disease to assume a grave and fatal form. 

Treatment. — Hygienic treatment. — In all cases of the disease, whether 
of the mild or grave kind, the strictest attention should be paid to the 
hygienic condition of the patient. The room in which the child is placed 
ought to be, if possible, large, and at all events well ventilated. The tem- 
perature in winter should be carefully attended to. We usually direct it 
to be kept at from 68° to 70° F., during the early stages of the disease, 
unless the fever is violent and the child complains of heat, in which case 
it may be allowed to fall to 66°, or even 62°. The clothing ought to be 
moderate, not enough to increase the heat of the skin, nor yet so little as 
to endanger chilliness. During the latter stages of the disease, when the 
fever has subsided, and particularly when the heat of the skin has fallen, 
the temperature of the chamber ought to be kept, as a general rule, at 
from 68° to 70°, and, when the child is pale, weak, and chilly, it may be 
maintained with great propriety at 72°. 

One of the most important points in the treatment of scarlet fever is, 
undoubtedly, the management of the patient during the convalescence, 
and especially during the desquamative period. It is during this period 
that the child is liable, as we have already shown in our account of the 
different complications and sequelae of the disease, to dropsy, which is 
the most frequent, and at the same time the most dangerous accident to 
which the patient is exposed. There can be no doubt, we think, from the 
opinions expressed by various writers, and also from our own experience, 
that the most common cause of this accident is exposure to cold. Chill- 
ing of the body, no matter how produced, is exceedingly apt, when it 
occurs within three, or, more rarely, four weeks from the invasion of 
scarlet fever, to be followed by a more or less marked attack of some 
form of dropsy. It is true, we are well aware, that dropsical effusions 
sometimes take place in subjects who have been guarded in the most care- 
ful possible manner, in whom there has been no evident exposure to cold; 
but it is also true, that a much larger number of those who have been 
thus guarded, escape, than of those who are not thus taken care of. We 
have, therefore, no doubt whatever, that it is most wise and prudent to 
confine the patient to well-warmed rooms, or at least to the house, for 
.twenty-one or twenty-eight days from the outset of the disease. The fact 



TREATMENT OF MILD CASES. 707 

that the attack has been a slight one only makes it the more necessary 
to cany out this regulation, as it has been found b} T experience that 
dropsy occurs more frequently after mild than after severe attacks. M. 
Legendre (Becherehes Anat.-Pathol, p. 311) is of opinion that the patient 
ought not to be allowed to leave the house until the skin, completely de- 
prived of the old epidermis, shall have regained its suppleness, its smooth 
and polished appearance, and all its functions. When, therefore, after a 
mild case, the desquamation is completel} 7 terminated in three weeks, the 
patient, he thinks, may be allowed to go out. But, on the contrary, this 
period would be too short b} r one-half, if the eruption had been very in- 
tense, as the desquamation is, in such cases, scarcely finished on the 
hands and feet at that time. Our own opinion, as already stated, is, that 
in the cool seasons of the year, the patient ought to be secluded in the 
house during full four weeks. 

The diet should consist in the early stage, as a general rule, of prep- 
arations of milk, or weak animal broths, according to the severity of the 
case and the state of the stomach. If the fever be very severe, barley- 
water, or arrowroot prepared with milk and w r ater, may be given. Nothing 
more substantial than these articles ought to be permitted, in most cases, 
until after the patient is decided^ convalescent, when broth with rice 
boiled in it, or plain boiled rice, and then some light meat in small quan- 
tity, may be allowed, until the child gradually resumes its old habits. 
When, however, the case runs on for a length of time, or symptoms of 
prostration come on, beef-essence may be given at once, and small quan- 
tities of wine whey, or weak milk punch added, according to the degree 
of the symptoms. 

Treatment of Mild Cases. — A large majority of these cases need but 
very simple treatment. Some laxative, as magnesia, castor oil, or syrup 
of rhubarb, in such dose as to procure two or three stools, may commence 
the treatment. After this a diaphoretic may be given every two or four 
hours. If the skin is very hot and dry, we prefer the antimonial wine and 
sweet spirit of nitre, in the dose of two to four drops of the former, with 
eight or ten of the latter ; or a teaspoonful of neutral mixture, with a little 
nitre or spirit of Mindererus, may be substituted. At the same time a 
bath should be administered. This may be either a common bath at a 
moderate temperature (94° to 96°), or an affusion bath, given in the fol- 
lowing manner : Prepare a bucketful of warm water (96° to 98°) contain- 
ing from half a pint to a pint of vinegar ; undress the child, and place it 
standing in a large tub, with its head and shoulders bent slightly for- 
wards ; then pour the vinegar and water from a pitcher over the body, 
letting it fall from a height of two or three feet, in a small, steady stream, 
on the nucha, so that it shall run over the whole surface and fall into the 
tub. The moment the bath is finished, wrap the child in a warm cotton 
sheet, over which should be put a light blanket, and lay it in bed, or hold 
it on the lap for twenty minutes or longer, if perspiration is induced, after 
which it is to be wiped dry and dressed. If the fever be violent and ac- 
companied with great dryness of the skin, two bucketsful of water may 
be used. This bath is often followed by copious perspiration and sound, 



708 SCARLET FEVER. 

refreshing sleep, with great diminution of the heat and restlessness. It 
may be repeated every three or four hours if necessary. If the case be 
so mild as not to require an immersion bath, a foot-bath maj T be used 
with great benefit as a sedative and diaphoretic. A moderate dose of 
some mild cathartic, or an enema, should be used from time to time 
through the course of the disease, if the bowels are not moved spontane- 
ously. This simple treatment will, we believe, carry a large majority of 
the mild cases to a safe termination. Sometimes, however, even while 
the disease pursues a regular, uniform course, the general or local symp- 
toms assume a degree of activity which renders more energetic treatment 
necessaiy. 

The febrile movement maj r be unusually active, and attended with so 
much restlessness, or b} r such an amount of delirium at night, as to 
threaten a change into the grave form of the malady. In cases of this 
kind it was customary at one time to use general or local depletion. Of 
late 3 T ears, however, we have entirely abandoned depletion in any form, 
having found it either unnecessary or hurtful. When there has been un- 
usual restlessness, with violent complaints of headache, in older children, 
without very great fever, a somewhat active cathartic may be given. It 
is necessary to be careful in the use of purgatives ; for it must be improper 
and unsafe to give those which are irritating, or such doses of others as 
might prove so, in a disease which, in its severe forms, shows a strong 
disposition to choleraic states of the bowels. We would rather, there- 
fore, give a medium dose of a laxative remedy, and repeat it from time to 
time, than run the risk of exciting by an overdose a condition of irrita- 
tion which could scarcely fail to do mischief by interfering with the regu- 
lar course of the malady. For these reasons we generally resort to mag- 
nesia, followed by lemonade ; to castor oil in orange juice, in the dose of 
a dessert-spoonful for children over three years of age, and a teaspoonful 
under that age ; to simple syrup of rhubarb in the close of a dessert or 
tablespoonful ; to a teaspoonful of salts ; or some similar remed}^ giving 
directions that the dose shall be repeated in six hours, or assisted by an 
enema, if it fail to operate. At the same time the affusion bath, as above 
directed, or the tepid immersion bath, ought to be used several times in 
the twenty-four hours, according to its effects, the temperature of the 
body, and the degree of restlessness. 

The angina needs no treatment whatever in a large majority of these 
cases. The physician should never, however, neglect to examine the 
fauces, when the case assumes any degree of severity*. If, under these 
circumstances, he finds evidence of severe inflammation of those parts, in 
the form of swelling, bright or deep redness, and yet more, patches of 
whitish exudation, he may fairly presume that this assists to occasion the 
unusual severity of the general s}^mptoms, and he should immediately 
a PPly remedies to check or modify the local disease. A great many dif- 
ferent local remedies are recommended b} T different authorities. Those 
of which we make most frequent use are weak solutions of nitrate of silver 
(five to twent}^ grains to the ounce), to be applied twice or three times a 
day ; tincture t>f the chloride of iron, diluted with from two or three to seven 



TREATMENT OF MILD CASES — INUNCTION. 709 

parts of water, or of a mixture of glycerine and water, applied in the same 
way. and a solution of sulphate of copper and quinine (six grains of each 
to an ounce of rose-water), which has been very much used and greatly 
depended upon by the late Dr. C. D. Meigs, and which we have found 
very beneficial. This is to be applied in the same manner as the solu- 
tion of nitrate of silver. With one of these we have alwaj'S succeeded 
very well in this class of cases. Rilliet and Barthez recommend the fol- 
lowing preparation : 

R. — Acid Muriat., f gj vel f^ij. ■ 

Mel Rosas, fgj — M. 

It is proper to avoid, under the circumstances above described, the use 
of caustic applications, as they are not needed, and as they might aggra- 
vate the local disease. 

It often becomes necessary, even in cases of this form, to employ tonics 
at some period of the attack; and there is none which can be used more 
advantageously than some one of the salts of quinia. 

Tr. ferri chloridi has been of late recommended in this as well as in the 
grave form of the disease, and its administration is asserted to have a 
tendency to prevent the development of albuminuria or dropsy. 

Within the last few j-'ears inunction has been highly recommended in 
the treatment of scarlet fever. It was first proposed and strongly urged, 
we believe, upon the profession, by Dr. Schneeman, a German physician. 
Dr. Schneeman makes use of bacon fat. He takes a piece about as large 
as the hand, still covered with its rind, in order to obtain a firm grasp 
upon it. On the soft side of the piece slits are made in various direc- 
tions in order to allow the oozing out of the fat. The patient is to be 
rubbed with this as soon as we are aware of the nature of the case, from 
head to foot, excepting the face and scalp, every morning and evening. 
The rubbing is to be so performed that the skin may be regularly but not 
too quickly saturated with the fat. During the process only the part 
being rubbed is to be uncovered, or the whole can be done under the 
bed-clothes. (Banking's Abst, No. 12, p. 26.) 

For our own part, we have never made use of the bacon fat for the 
purpose of inunction, except in two instances, being deterred by its dis- 
agreeable character. We have, however, employed inunction with other 
unctuous substances very frequently. Indeed, for a number of years 
past, we have made use of it habitually in our cases. The ointment we 
prefer is the following. We have tried others, but find this one the most 
agreeable and most convenient: 

R.— Glycerinse, f^j. 

Ungt. Aq. Kosar., gj. — M. 

There can be no doubt, at the present time, that the employment of 
inunction in scarlet fever has proved a most useful addition to our former 
means of treatment. In our hands it has had the effect of allaying, in all 
cases, the violent irritation caused by the intense heat and inflammation 



710 SCARLET FEVER. 

of the skin. In nearly all cases, it sensibly diminishes the frequency of 
the pulse, and in many this effect is very strongly marked. It removes, 
of course, the dryness and harshness of the skin, keeping it, instead, soft 
and moist. It lessens or even removes the burning, irritation, and itch- 
ing, caused by the eruption. By these effects, to wit, lowering of the 
pulse, and alleviation of the external heat, dr} T ness, itching, and irrita- 
tion, it cannot but and evidently does modify and diminish, most happily, 
the injurious effects of the disease upon the constitution at large. So 
great is the comfort it gives to the patient that we have several times had 
young children, still untaught to speak, to make signs and motions, at 
shorter or longer intervals, showing their desire to have the application 
renewed. The frequency of the application must depend upon the case. 
When the eruption is intense, the skin very hot, and the febrile symptoms 
marked, they should be made every two or four hours, or even often er. 
In milder cases they need to be repeated only three or four times in the 
twenty-four hours. 

Treatment of grave cases. — Since the publication of the last edition of 
this work, we have entirely abandoned the use of depletion in any form 
in grave cases of scarlatina, believing it to be contraindicated, and con- 
demned both by sound theory and universal experience. 

Purgatives ought to be used with care, and only in such doses as to 
secure a soluble state of the bowels, and never to cause diarrhoea. At 
the onset of severe cases, attended with prostration and malignant S3 T mp- 
toms, in particular, the exhibition of large doses of active cathartics 
ought to be carefully avoided. It cannot but be injurious to perturbate 
violently so important a system as the digestive, and through it the 
nervous system, in a disease like scarlet fever, in which nature is about 
to throw out an intense eruption upon the skin, and in which there is 
alreacty only too much disposition towards disorder of the nervous actions 
of the body. 

The antiseptic salts of soda and magnesia, especially the hyposulphites, 
have been highly recommended by Polli, of Milan, upon the ground of 
their checking the fermentative action of the scarlatinous poison in the 
blood. We have used them in 11 cases, of which 3 were malignant, 2 
severe, and the remaining 6 regular, and all of which terminated favor- 
ably. This experience is too small to base any positive opinion upon ; but 
we are disposed b}^ it to hope that these remedies may be found beneficial. 
At five 3'ears of age, five grains of the hyposulphite of soda every two 
hours ; and at ten years, ten grains every two hours, are the doses we 
have employed. 

Chlorate of potash is also recommended by several authorities, and by 
some with high commendation. Dr. Watson dissolves a drachm of the 
salt in a pint of water, and gives it as a drink to the patient. We have 
made use of it in several cases, and are of opinion that it was decidedly 
beneficial in some in which the throat and mouth were very much inflamed 
and disposed to ulceration. 

Inunction, emplo3 T ed as described in our remarks upon the treatment 
of mild cases, will be found of great service whenever the skin is very hot 



TREATMENT OF GRAVE CASES. 711 

and dry, and particularly when the eruption is intense and accompanied 
with violent itching and irritation. 

Bath*: lotions; affusions. — We are disposed to believe that, on the 
whole, we derive as much benefit, in grave cases of scarlet fever, from the 
judicious external employment of water, as from any other means of treat- 
ment. The particular mode in which it is to be made use of must depend 
on the character of the individual case. In some the warm, in others, the 
cold bath ; cool, cold, or tepid lotions ; or affusions with water at various 
temperatures, must be applied according to the nature of the case. We 
shall refer first to the opinions of different authorities upon this subject, 
and then give the results of our experience in the matter. 

The warm bath is recommended when the cutaneous action is slow and 
imperfect, the pulse rapid and small, and the nervous actions slow or 
irregular, or, in other words, in cases of an asthenic type, in which the 
disease assumes a low and typhoid disposition. 

Lotions, by sponging with water at different temperatures, are highly 
recommended by many authors, and ofteu afford the best means of mod- 
ifying the condition of the cutaneous surface. They are most useful 
when the skin is intensely hot and dry, and should then be employed at 
a temperature of from T5° to 90° or 92°, according to the degree of the 
cutaneous heat, and according also to their effects at the moment. They 
are to be continued for several moments, or for half an hour even, until 
the heat is reduced and the restlessness of the patient moderated. To be 
of any service the}' must be repeated so soon as the temperature of the 
skin rises again after it has been reduced by previous sponging. Usually 
it is necessaiy to resort to them every Jiour or two hours, or even more 
frequently. It is scarcely needful to say that cool or cold lotions are to 
be used only when the reaction is strong and well marked, and not when 
the skin is pale and cool, aucl the pulse feeble and rapid. Under these 
latter circumstances, lotions w T ith warm or hot water, or warm or hot 
baths, in connection with internal stimuli, would be the proper remedies. 

We come now to the consideration of another method of treatment, 
which has been asserted to be most efficient in the violent forms of the 
disease by several persons of high authority in medicine,. while by others 
it is considered dangerous and improper. We refer to the use of affusions 
with cold water. The treatment was particularly relied on by Dr. J. Cur- 
rie, of Edinburgh. Let it be observed, however, that Dr. Currie limits 
its use to cases to which he applies the term anginose, many of which, we 
doubt not from his description, ought to be classed as mild cases. He 
mentions another class of cases, which he thinks ought rather to be called 
"purpurata," characterized by "extreme feebleness and rapidity of the 

pulse, and great fetor of the breath The heat does not rise much 

above the standard of health. Great debility, oppression, headache, pain 
in the back, vomiting, and sometimes purging, accompan}" its rapid prog- 
ress ; the patient sinks into the low delirium, and expires on the second, 

third, or fourth day The cold affusion is scarcely applicable to 

it, and the tepid affusion makes little impression upon it. In m} T experi- 
ence, indeed, all remedies have been equally unsuccessful. It outstrips 



712 SCARLET FEVER. 

in rapidity, and it equals in fatality, the purple confluent smallpox, to 
which it may be compared." (Curriers Med. Reports, Philada.,p. 27*7.) It 
is clear, therefore, that Dr. Currie, when he speaks of nearly invariable 
success in upwards of one hundred and fifty cases (p. 286), had to do, not 
with the malignant, or, at least, not with the most malignant forms, for 
which we are seeking a remedy, but with cases of a mild form, or at most 
with those of the severe anginose type. Indeed, at page 294, we find the 
following remarks : " It has come to my knowledge, that in two cases of 
scarlatina, of the most malignant nature, the patients have been taken 
out of bed, under the low delirium, with the skin cool and moist, and the 
pulse scarcely perceptible. In this state, supported by the attendants, 
several gallons of perfectly cold water were madly poured over them, on 
the supposed authority of this work! I need scarcely add that the effects 
were almost immediately fatal." We have been induced to enter thus 
much into detail, in regard to the use of cold affusions, because of the 
intrinsic importance of the subject, and because of the remarks upon it in 
the work of MM. Rilliet and Barthez, who bring forward Currie's success 
as a strong argument in favor of their employment in that form of the 
disease in which cerebral sj'mptoms predominate. Currie does not rec- 
ommend them, however, except in cases in which the reaction is full and 
strong, as indicated by very great heat of skin, scarlet eruption, and 
rapid, but not feeble pulse. In the famous cases of his own two children, 
it is evident that the attacks were not malignant, for the skin was very 
hot (108° and 109° F.), and no mention is made either of stupor or de- 
lirium, much less of convulsive phenomena. Dr. George Gregory, of 
London, whose opinions upon ail matters connected with the eruptive 
fevers are of course worthy of great weight, says (Lee. on the Eruptive 
Fevers, edited by Dr. Bulkle}', New York, p. 190), in relation to the use 
of cold affusions : " Sanctioned by my uncle, the late Dr. Gregory, of 
Edinburgh, this plan has been amply tried in all parts of the world, but 
it has not realized the expectations of its proposer. 

" The truth is that the cold affusion is applicable only to a small number 
of cases. It is adapted for young people with high anginose inflammation 
and a burning hot skin, without plethora, without depression of nervous 
energy ; but it is inapplicable to the scarlatina of adults, accompanied 
with coma, phrenitis, or marked clebili^. It is wholly unfit for cases of 
cynanche maligna. It answers its purpose very well for the first day or 
two, but it is often impossible to continue its use. Lastly, it seems to 
increase the disposition to dropsy." 

The evidence brought forward by Currie, Gregory of Edinburgh, and 
MM. Rilliet and Barthez, in favor of the efficacy of cold affusions in the 
treatment of severe cases of the disease, is such, however, as ought to call 
attention to this point, though our own impression is that lotions with 
cool or cold water are safer, more agreeable to the patient, more conve- 
nient in every respect, and quite as useful as cold affusions. If emplo} T ed 
at all, they ought evidently to be restricted to cases, in which the reaction 
is perfectly well marked, in which the skin is hot and dry, the pulse, 
though frequent (150 or 160), strong, and the eruption not of too dark a 



TREATMENT OF GRAVE CASES — COLD AFFUSIONS. 713 

tint. The child is to be undressed and placed erect or sitting in a tub, 
while four or five gallons of water, at from 60° to T0° F. are poured over 
the head and body. The good effects of the remedy are said to be an 
immediate reduction of the heat, a diminution in the rapidity of the pulse, 
which' in one of Dr. Gregory's children fell in half an hour after the cold 
affusion from 160 to 120, a disposition to sleep and quiet, and, according 
to Dr. Gregory, a seeming arrest of the throat-affection. These good 
effects of the affusions are transient, however, as the heat of skin and 
rapidity of the circulation return in the course of one or two hours. For 
this reason it is necessaiy to repeat them frequently, once in two or three 
hours at least, in order to render the effects permanent. Currie used 
fourteen affusions for one of his own children, and twelve for another, in 
thirty-two hours. These were not, however, all cold. Gregory used for 
his child five " good sousings," to use his own words, in twenty-four hours. 

This measure has been extensively employed by Dr. Hiram Corson, of 
Montgomery County, Penns}ivania, and with remarkable success in at 
least one epidemic of the disease. Dr. Corson, however, used cold appli- 
cations even more vigorous! j r than as above described. He applied ice, 
wrapped in cloths, to the throat externally, and caused small pieces to be 
held in the mouth; and bathed the entire body, in some cases for hours 
together, with iced water, applied by means of large sponges. The effects 
of this were a marked subsidence of the nervous symptoms, the frequency 
of the pulse, the heat of the skin, and intensity of the eruption ; and in 
no instance did any unfavorable results follow the application. Care was, 
of course, taken not to prolong the cold applications where evidences of 
their depressing action made their appearance. 

MM. Rilliet and Barthez give in the following words the conclusions of 
Henke in regard to the use of cold affusions : 1. Cold affusions are not 
adapted for a general method of treatment. 2. The slight, or simply in- 
flammatory forms, do not all demand so energetic a treatment. 3. Their 
employment must be reserved for cases in which the disease is epidemic, 
and accompanied by intense heat and dryness of the skin, with smallness 
and acceleration of the pulse, and for those in which the cerebral symp- 
toms are very violent and characterized by great restlessness, alternating 
with drowsiness, commencing from an early period of the disease. Scarlet 
fever under these circumstances, is so dangerous, they say, and so often 
mortal, that recourse ought to be had to all curative means, and in chil- 
dren the cold affusions are much more strongly indicated than bleeding 
(op. cit, vol. ii, p. 653). 

Both Gee (Reynolds's Syst. of Med., vol. i, loc. cit.) and Hillier (loc. cit.) 
speak of having seen marked benefit follow the use of cold affusion in 
severe cases, attended by delirium, vomiting, diarrhoea, full pulse, and 
great heat of skin. In cases where the affusion has been inadmissible 
they recommend "packing" the patient in sheets wrung out of cold water, 
and then enveloping him with several blankets; after remaining thus for 
about an hour he should be taken out and put to bed as after an affusion. 

Our own experience in the use of cold applications has not been very 
extensive, as we have preferred the use of the tepid affusion bath, of im- 



714 SCARLET FEVER. 

mersion baths, and of lotions with tepid or cool water. We have never 
employed the cold affusion over the whole body, and never saw it em- 
ployed but once. In that instance a single bucketful of water at 10° 
was poured over the child, but, as it was not repeated, no good effects, 
beyond a very transient reduction of the heat and quiet for a short" time, 
were produced. In another instance, we made repeated affusions upon 
the head with water at 70°, pouring at one time seven bucketfuls upon 
the part. This was a case attended with coma, strabismus, and spasmodic 
retraction of the head. In addition to the affusions, cloths clipped into 
iced water, were kept applied the greater part of the time. These means, 
especially the affusions, were evidently advantageous, and the child re- 
covered. 

We are disposed, on the whole, to believe that, in such cases as those 
above referred to, the free use of ice and cold water externally, may be 
productive of great benefits. The excellent results obtained by these 
remedies in the treatment of cases of sunstroke, attended with very high 
temperature, encourage us to hope much from their employment in severe 
scarlatina where the heat of skin is very intense. 

We have made use of lotions with cool water (70° to T2°) in three 
grave cases. In two they were evidently useful ; in one they did no good, 
and were perhaps injurious, as we believe now that the case might have 
been better treated with prolonged warm baths at a temperature of 92° 
to 95°, cold to the head, and internal stimulation. The latter case was 
one in which the patient had two convulsions on the first day, and one on 
the second. The pulse rose at once to between 160 and 110 ; the head and 
trunk were very hot, whilst the extremities were coolish ; the child was 
either excessively dull or comatose. Cloths wet with iced water were kept 
constantly upon the head and the body, and occasionally the limbs were 
sponged with cold water. The internal remedies consisted of carbonate 
of ammonia and milk-punch. The patient improved decidedly on the 
third day, so that the pulse came down to 152, the intelligence returned, 
though the child was still very drowsy and heavy, and the case looked quite 
promising. On the fourth and fifth daj^s, the throat-affection came on ; 
the neck and throat swelled enormously, the cervical lymphatic glands 
became very large, the nasal passages discharged streams of offensive 
grumous pus, the ears ran copiously, the fauces became pseudo-mem- 
branous, the deglutition grew worse and worse, until at last it was impos- 
sible, and the child died on the middle of the sixth day, a mass of the 
most disgusting and offensive disease. One of the grave cases in which 
the cool applications proved useful, occurred in a hearty, vigorous girl, 
twelve years of age. On the third day of the attack, the s^ymptoms were 
as follows: the pulse was between 160 and 170, small and quick; skin 
intensely hot ; eruption very copious and of a dark red color, tending to 
violet; capillary circulation slow and languid; tongue black, and covered 
with a hard dry crust; teeth and lips dry, and covered with dark incrus- 
tations. There was very great agitation and restlessness, with constant 
moaning and complaining, and total insomnia. Under these circum- 
stances, we directed the nurse to sponge the head and extremities of the 



TREATMENT OF GRATE CASES BY BATHS, LOTIONS, ETC. 715 

patient with water of the temperature of the room (68° to 10°). As the 
water became heated by contact with the skin, small pieces of ice were 
put into the basin so as to keep the temperature at the point mentioned. 
At the end of four hours, the washing having been continued all the time, 
we found the patient decidedly more comfortable. The pulse had fallen 
to 140. and increased in volume ; the heat of skin was much reduced ; the 
color of the eruption had improved, having become much more scarlet in 
tint : the capillary circulation was more active ; the agitation and restless- 
ness had very much moderated, and the child had slept somewhat at short 
intervals. This treatment, in conjunction with the internal administration 
of the solution of chlorinated soda, and small doses of spirit of turpen- 
tine, was continued for several da}<s, the sponging being used whenever 
the heat and restlessness were great, and the pulse very rapid. The child 
convalesced about the end of the third week, but was unfortunately seized 
with uroemic symptoms on the twent3 T -fifth day, and died in twenty-three 
hours, after the most frightful convulsions we ever saw. 

Without attempting to describe more particularly our experience in 
individual cases, we shall proceed to give a summary of what we believe 
to be the best mode of emphyying the class of remedies now under con- 
sideration (baths, lotions, and affusions). Of the various means that we 
have emploj-ed or seen employed in grave cases, these alone, either singly 
or in connection with the use of stimulants, have seemed to us to exert a 
manifestly beneficial influence upon the disease. In cases attended with 
low delirium, stupor, or coma, or with convulsive phenomena, in which 
the extremities are cool or coolish, even though the head and trunk may 
be intensely hot, and where the eruption is scanty and imperfect, or co- 
pious and of a dark and purple tint, the warm bath at 95° and 96°, con- 
tinued for twenty minutes or half an hour, and repeated every two or 
three hours, in connection with the internal employment of stimulants, 
as ammonia and brand}' ; and with cold to the head, either by means of 
wetted cloths, or b} 7 a prolonged cold douche ; and occasionally a few dry 
cups on the head, afford the best means of treatment that we are ac- 
quainted with. Under these circumstances, the warm bath has always 
appeared to ameliorate for the time being the condition of the patient. 
From being entirely comatose, or exceedingly heavy or delirious, the 
child has, while in the bath, often awakened from its stupor and regained 
a slight degree of intelligence, so as to open its eyes, look round, and 
drink freely. In cases attended with convulsions, the warm bath, with 
cold cloths to the head, or better still, a prolonged cold douche upon the 
head, will very generally cause the cessation of the convulsive s} r mptoms. 
Unfortunately, however, the effects of this treatment are only too fre- 
quently but transient, for, though the heat of the skin has remained 
"rather less for some time after the immersion, the coma and sometimes 
the>disposition to convulsions have very soon returned. The same state- 
ments are made by M. Gueretin (loc. cit., p. 302). Nevertheless, these 
means, the frequently repeated warm bath, cold to the head, and internal 
stimulation, offer, we believe, the best means that have as yet been dis- 
covered of treating those malignant cases in which, within a few hours 



716 SCARLET FEVER. 

from the moment of invasion, the patient lies before us comatose or con- 
vulsed, stupid or delirious, with a scanty or dark-colored imperfect erup- 
tion, with coolish or cold extremities, and with small, feeble, and very 
rapid pulse. 

In cases of scarlet fever not quite so severe as those just now alluded 
to, in which the pulse, though very frequent, remains somewhat full and 
strong, in which the cutaneous heat is very great and properly distributed, 
in which, though the patient is heavy and dull, he is not comatose nor con- 
vulsed, or if convulsed onty momentarily so, and that from the intensity 
of the febrile reaction, and in which, if delirium exists, it is slight and of 
a higher kind than in the previous class of cases, the most suitable treat- 
ment is the following. The affusion bath of vinegar and water, as recom- 
mended in our remarks upon the treatment of mild cases, should be used 
eveiy two or three hours, at a temperature of from 90° to 95°; after the 
bath the child should be wrapped in a cotton sheet, and placed in bed in 
a light blanket, for twenty minutes or half an hour; when dry, the body 
should be rubbed all over with the ointment alread}^ described. The 
head is to be kept cool by means of wetted cloths. The only treatment 
necessaiy is a mild laxative, iced drinks, as lemonade, orangeade, or 
mineral waters, the chlorate of potash solution alread}' spoken of, neutral 
mixture, and sweet spirit of nitre, or spirit of Mindererus. When, from 
any cause, as want of the necessary conveniences, or from the terror it 
sometimes inspires in the child, the affusion bath cannot be employed, 
we ought to make use, instead, of tepid or cold spongings and of in- 
unction. 

In 3'et milder cases than those just described, in which though the 
pulse is frequent, it is quite full and strong, in which the eruption is 
abundant and bright in tint, and the whole cutaneous surface hot and 
dry, and in which the nervous symptoms are not of a veiy threatening 
character, the only external means necessary to be used, are an occa- 
sional tepid immersion bath, or better still, a warm affusion bath, or else 
frequent spongings with tepid or coolish water, and frequent inunction. 
The internal means should consist, as in the previous class of cases, of 
cool and refrigerant drinks and simple diaphoretics. 

Tonics and stimulants. — In certain grave cases of scarlet fever stimu- 
lants are required from the very commencement of the attack — at least 
such is the opinion of some of the best medical authorities, and such also 
is the conclusion to which experience has brought us. Whenever, there- 
fore, from the beginning, the pulse is small, feeble, and rapid, the cuta- 
neous action imperfect, as shown by a scanty or irregular eruption, or by 
one of a dusky or purple color, in which the movement of the blood in 
the capillaries is sluggish, in which the temperature of the bod}' is uneven, 
the extremities being cool, whilst the head and trunk are hot, in which 
the patient is dull, stupid, comatose, or affected with low delirium, and 
in which low nervous s3 T mptoms, as irregular muscular movements, ex- 
cessive jactitation, automatic movements, or subsultus tendinum, are 
present, it is evidently proper and necessaiy to make use of stimulants 
and tonics. The drugs which we would recommend most highly in such 



TREATMENT OF THE ANGINA. 717 

conditions are the carbonate of ammonia, quinia, or Huxham's tincture 
of bark, and tincture of the chloride of iron; at the same time we would 
advise the use of the hyposulphite of soda, as alread}' mentioned. It is 
also necessary to emplo}' concentrated food, such as beef-tea, Liebig's 
cold extract of beef, egg beaten up in milk, and stimulants, such as wine 
whey, milk punch, or brandy and water. It ought not to be forgotten, 
moreover, that while these remedies are being employed, the hot, warm, 
or tepid bath, prolonged for some length of time, and repeated every two 
or three hours, or spongings, with cold to the head by means of wetted 
cloths or Ivy a cold douche, and frequent inunction, constitute quite as 
important a part of the treatment. 

In slow and tedious cases of the disease, which perhaps were of a more 
sthenic type in the beginning, ad3 T namic s}anptoms frequently occur after 
the attack has been going on for one or two weeks. The pulse becomes 
frequent and small, the skin cool and moist, or hot and cold by turns, the 
tongue is dry and cracked, sordes collect upon the teeth, and there is 
jactitation, muttering delirium, and various nervous symptoms, which all 
clearly indicate great exhaustion of the vital powers. Under these cir- 
cumstances it is necessary to resort to whatever means are likely to up- 
hold the constitution, and impart to it strength to resist the slow disease 
which tends to destroy it. With this view we should resort to the same 
tonic and stimulating plan of treatment, in conjunction with the use of 
concentrated nourishment, as recommended above. The amount of stimu- 
lus administered must of course be regulated by the condition of the 
pulse, the character of the nervous symptoms, and the general evidences 
of prostration present. 

Treatment of the Angina. — The pharyngeal inflammation requires a 
chief share of our attention in all grave cases of the disease. 

If the reaction be full and strong, and the inflammation and swelling 
of the throat very great, it may be permissible to apply one or two leeches 
to the angles of the jaw; but even in these cases this measure may prob- 
ably be dispensed with, while in the graver forms of the disease it should 
be entirely avoided. 

When the external swelling is considerable, benefit is sometimes de- 
rived from the steady application of warm poultices to the part. They 
should be inclosed in portions of thin, soft flannel, and secured by means 
of a very light cravat ; they must be renewed every two or three hours. 
Applications of spongiopiline, wrung out of hot water, are a convenient 
and efficient mode of obtaining warmth and moisture. In cases attended 
with great heat of the skin and fully developed pulse, cold applications 
to the throat, consisting of pieces of ice wrapped in flannel, and applied 
behind the angles of the jaw, or of cloths wetted with iced-water, may 
very properly and, we believe, advantageously be made use of. In one 
case in which we made use of the cold cloths, they were evidently bene- 
ficial. In another case, in a boy between eight and nine years old, 
already referred to, there appeared on the third day threatening an- 
ginose symptoms. Oh the fourth these had increased, and by the night 
of the fifth day had reached such a height as to make us almost despair 



718 SCARLET FEVER. 

of the child's life. The violent phar} T ngeal inflammation was attended 
with excessive swelling of the tonsils, and with cedematons infiltration of 
the submucous tissue, while externally the cervical glands were enor- 
mously enlarged and as hard as paving-stones, and the subcutaneous 
tissues of the front and lateral regions of the neck were packed and hard 
with acute oedema. The general s^ymptoms were most threatening. Owing 
to the swelling of all the parts composing the neck, the respiration was 
so much interfered with as to cause the development of dangerous as- 
phyctic symptoms. The pulse, which for the three first chrys had been 
running at 168, had fallen on the fourth to 140, and on the fifth to 128; 
the skin was hot and dry, and upon the face had assumed a dark, bluish 
tint ; there was almost constant muttering delirium and a degree of toss- 
ing and violent jactitation painful to witness. The swallowing was so 
much impeded that it was with great difficulty that the patient could take 
the thinnest liquids. Up to this time the case had been treated with in- 
unctions, cold drinks, and a febrifuge containing spirit of Mindererus 
and sweet spirit of nitre. In the midst of these threatening symptoms, 
and when we had almost lost hope, the late Dr. Charles D. Meigs, who 
saw the case with us, proposed abandoning all drugs, and making use of 
cold applications externally, and giving stimuli. Accordingly a large 
towel was wrung out of iced-water and wrapped around the neck, and 
weak wine and water was given as often as the child could take it. The 
cloth was dipped afresh into the water every few minutes. This treat- 
ment was commenced about 1 a.m., and carried on steadily all night. At 
9 a.m. it was evident that the S3 T mptoms had somewhat improved, and by 
the afternoon of that day the patient was greatly better. The improve- 
ment consisted principally in a moderation of the pharyngeal swelling, 
so that both respiration and deglutition were much easier. The dark 
color of the face had lessened; the pulse had risen in frequenc}', and was 
stronger; and the delirium and excessive jactitation had almost disap- 
peared. On the da}' after this the external cervical swelling continued 
very much the same, except that the oedema had notably diminished. 
The phaiyngeal swelling had disappeared, the tonsils having regained 
their natural size, but the whole pharynx was covered with a thick mould 
of white exudation. The cold application, which of late had been used 
more sparingly, was now discontinued ; the fauces were touched with a 
solution of nitrate of silver of ten grains to the ounce; broths, milk, wine- 
whey, and wine and water were given for nourishment, and the patient 
slowly recovered, after having had a large suppuration just above the 
inner end of the left clavicle. 

A great variety of local remedies have been proposed b} T different au- 
thorities. The best of all are, in our opinion, weak solutions of nitrate 
of silver (five to twenty grains to the ounce), tincture of the chloride of 
iron, diluted with from two to seven parts of water ; and solutions of the 
sulphate of iron, of from twenty to fort} r grains to the ounce. 

In the use of any of these preparations in children, it is necessary to 
apply them to the fauces in the manner described in the article on diph- 
theria. When viscous secretions collect in the fauces in such quantity 



TREATMENT OF THE DROPSY. 719 

as to cause serious annoj-ance to the child and embarrass the respira- 
tion, they ought to be removed by means of a sponge-mop or camel's- 
hair brush. This point in the treatment is a very important one, espe- 
cially in young children. We believe that we have rescued more than 
one patient by going three or four times a day to make use ourselves 
of means by which to remove from the fauces the viscid, glue-like 
secretions, the purulent fluids, and the masses of pseudo-membranous 
exudation which collect in and occlude those passages, and which the 
child often cannot, by any effort of its own, get rid of. The best mode 
of effecting this object is by the use of mops made of sponge or rag, 
fastened to a stick or whalebone, or by the injection from a small 
syringe or elastic bottle of detergent washes or gargles into the throat, 
the mouth being held open and the tongue depressed by the handle of a 
spoon. One of the best washes for this purpose is made of a strong de- 
coction of green tea containing alum ; or we may employ sage tea and 
alum ; or hone}' of roses and borax mixed with water ; or capsicum tea ; or 
lime-water ; or, what is highly recommended b}^ Dr. Watson as one of the 
best, a solution of common salt. When coryza is present, the nasal pas- 
sages should be cleansed by means of camel's-hair brushes, or by the 
injection of some of the mild washes just referred to, and then freely 
anointed with sweet oil or some mild ointment, or they may be touched 
with the wash used for the throat. To perform these little offices for the 
child almost always requires force, but they are followed by such com- 
parative ease and comfort, and, we doubt not, such mitigation of the dis- 
ease, that the}' ought to be insisted upon. 

Diarrhoea, when present, probably depends on congestion and desqua- 
mation of the intestinal mucous membrane, and should be treated with 
bland demulcent drinks, and absorbent antacids, especially chalk mixture. 

Rheumatism should be treated by opiates to allay the pain, and the 
swollen joints should be enveloped in bats of cotton. If suppuration 
should occur, either in connection with the rheumatic inflammation of the 
joints, or involving the glands or cellular tissue, and indicating a pysemic 
tendency, large doses of quinia with stimulants should be given. The 
abscesses which may form should be opened so soon as fluctuation can be 
detected. 

For the otorrhcea which sometimes occurs, it is seldom necessary to do 
more during the violence of the attack, than to cleanse the ears twice or 
three times a day, by syringing with warm water and castile soap, or with 
a weak solution of alum. After the violence of the attack has subsided, 
this complication should be treated as in idiopathic cases. 

Treatment of the Dropsy. — In slight cases, the only treatment necessary 
is the use of some mild purgative, as castor oil or magnesia ; a simple 
diuretic, such as cream of tartar or lemonade with sweet spirit of nitre, 
and an abundant supply of water ; hot baths repeated from time to time ; 
carefully regulated diet, and strict confinement to bed. 

In severe cases, marked by considerable fever, and in which the urine 
is scanty, high-colored, and loaded with albumen, or in which it is dark- 
colored, owing to the presence in it of blood, the treatment must be some- 



720 SCARLET FEVER. 

what more active. If the patient is not pale and weak, a few dry cups 
niay be applied over the loins with advantage ; but it can scarcely ever 
be desirable to withdraw blood, even locally. Subsequently, counter- 
irritation rna} T be kept up over the loins, as b} T the application of hot sand 
or salt bags. In addition to this, the most important part of the treat- 
ment consists in the use of hot baths, and in the administration of diu- 
retics. 

The bowels should be kept slightly relaxed b}^ doses of cream of tartar, 
or compound jalap powder ; but active purgation has not been as benefi- 
cial, in our own experience, as the use of diuretics and diaphoretics. 

We always employ diuretics, even from the very early stage, and haA'e 
never known them to produce any other than a beneficial effect. 

The ones that we prefer are the cream of tartar and juniper berries, one 
drachm of each of which may be infused in half a pint of boiling water, 
and the whole of the clear fluid taken in the course of the day ; or tincture 
of digitalis and syrup of squill with acetate of potash, as follows : 

R. 



Potass. Acetat., 


• ■ Bij- 


Tinct. Digital., 


. gtt. xlviij. 


Syrup. Scillse, 


. f£j yel ij. 


" Zingib., 


• • f3YJ- 


Aquae Fluvial., 


. . fgij.-M. 



Give a teaspoonful every three hours to a child three or four years old. 

Infusion of digitalis may also be given as a diuretic, in the dose of 
half a fluidrachm of the officinal infusion, equivalent to one-half grain of 
the powdered leaves, four times a day at the age of five years. This 
amount may be increased gradually, but in using this drug in any form, 
it is of course necessary to watch closely its effects upon the pulse. 

One of the best diuretics, and one that we have often employed with 
much satisfaction, is the compound spirit of juniper, with sweet spirit 
of nitre and bitartrate of potassa, as follows : 



R.— Potass. Bitart., 

Spts. Junip. Comp. , 
Spts. ^Ether. Nitros., 
Syrup. Simp., .... 
Aq. Fluvial, .... 

Give a teaspoonful every two hours. 



3)'- 

f 3 v. 
fgij — M. 



When the case is attended with fever and diyness of the skin, we often 
combine with the above some syrup of ipecac. ; when, on the contrary, 
the patient is languid and exhausted, we substitute spirit of Mindererus. 

Whichever of these may be employed, the patient should always be en- 
couraged to drink freely of water. The importance of this, as tending to 
increase the secretion of urine and prevent obstruction of the renal tubules, 
cannot be over-estimated, 

In addition to the use of diuretics, it is of the utmost importance to 
promote the action of the skin. By far the most powerful remedy for this 



PROPHYLACTIC TREATMENT. 721 

purpose is the use of baths, either of hot water or hot air. These may be 
given daily, or even more frequently, and after the bath, diaphoresis 
should be encouraged by wrapping the patient in flannels. 

In cases in which cerebral symptoms, such as violent delirium, coma, or 
convulsions, appear, usually depending upon uraemia, local depletion may 
be practised by cups or leeches to the back of the neck or loins, but it 
has not seemed to us that much benefit follows its employment. Active 
doses of cathartics ought to be given immediately, and if the sj^mptoms 
are very urgent, enemata may be employed to hasten their operation. 
The use of diuretics and hot baths, as before recommended, should also 
be fully carried out. In some cases there is such irritability of the 
stomach that no remedies will be retained, and we must then rely upon 
hot baths, purgative enemata, and counter-irritation to the back of the 
neck or the extremities. Thus in one case that came under our observa- 
tion, in which there was an almost comatose state with total suppression 
of urine for five daj T s, the stomach was so irritable that no remedy scarcely 
could be retained. The child, nevertheless, recovered finally, under the 
use of watermelon-seed tea, given frequently in small quantities, mustard 
foot-baths, and blisters behind the ears. 

In the less acute stages, the treatment should be somewhat different. If 
haematuria persists, gallic acid should be tried, and will often arrest the 
discharge of blood. If, however, it fails, or if the urine, though abundant, 
continues albuminous, there is no remedy from which so much good may 
be expected as iron, given in the form of tr. ferri chloridi or of the per- 
chloride in solution. Basham's diuretic iron mixture is exceedingly 
useful in these circumstances. Quinia is also of marked service when 
the disease has lasted some little time. 

Diuretics need not be discontinued, and if dropsy persists, they should 
be empkyved, together with diaphoretics and occasionally a hot air bath. 

If pleurisy with extensive effusion should supervene, the same general 
treatment should be adopted, and in addition, blisters may be applied. 
Paracentesis is rarely advisable because the effusion is usually bilateral, 
and there is apt to be pneumonia. 

Prophylactic treatment. — It has been asserted that belladonna, used by 
persons exposed to the contagion of scarlet fever, has the power of im- 
parting perfect or nearly perfect immunity from its attacks. Our own ex- 
perience in regard to this matter is so moderate, from the fact that we 
have not resorted habitually to the belladonna as a means of prevention 
until lately, that any opinion we can offer is worth but little. We have r 
however, used it a good deal during the last few years, and, though we 
have no exact data by which to form an opinion, the impression we have 
received is decidedly favorable, — so much so that we always make use of 
it now when the cases are severe, and especially when the type of the 
epidemic is dangerous. In one family, in which we gave it to nine chil- 
dren exposed directly to the disease, either from their being in a house 
in which it was prevailing, or in the very room of the patient, eight 
escaped the disease entirely, and the one who had it, had it very mildly 

46 



722 SCARLET FEVER. 

and safely. From the evidence brought forward in the European works 
that we have seen, its efficacy seems to be left in considerable doubt. 
MM. Rilliet and Barthez are of opinion, however, that it is at least 
wortlrr of trial. M. Cazenave (loc. cit., p. 58) states that "M. Biet saw 
the disease reign epidemically in one of the lofty valle} T s of Switzerland, 
and respect, almost without exception, children to whom the belladonna 
had been administered." MM. Guersant and Blache (loc. cit., p. 180), 
after citing various accounts of its use, conclude that "these trials ought, 
undoubtedly, to be continued." According to Dr. Conclie (loc. cit, pp. 
441, 442), Dr. Irwin made an extensive trial of its prophylactic powers in 
South Carolina, and found that of two hundred and fifty children who 
took it, less than half a dozen had the disease, and that very mildly. Dr. 
McKee, in an extension of the same epidemic, used it with like success. 

Dr. Conclie himself made use of it, "but although redness and cliyness 
of the throat, and a diffuse scarlet efflorescence were produced in the 
majority of the cases, we never found it in any, to exert the slightest in- 
fluence in mitigating the character, or preventing the occurrence of scar- 
latina. The experiments were made during the prevalence of the disease, 
and in numerous instances the subjects of them were attacked. In one 
case the efflorescence was kept up by the use of belladonna, forty-eight 
hours ; in a week afterwards, this individual took the disease in its most 
violent form, and died on the fourth day." 

By far the most thorough and careful examination of this interesting 
and important matter that we are acquainted with, has been made b} T Dr. 
F. Peyre Porcher (Charleston Med. Jour, and Rev., July, 1851). Dr. 
Porcher states that his paper contains the results of an examination of 
about four hundred volumes. Towards the end of the article (p. 476), 
•Dr. Porcher gives us his conclusions in the following words : " In review- 
ing the testimon}^ afforded by the preceding facts, our opinions, if we are 
allowed to express them, are decidedly in favor of the prophylactic powers 
of belladonna. However some may- consider the evidence of a negative 
character, and therefore unworthy of confidence, yet, from its cumulation, 
from the careful way in which some observers conducted their inquiries, 
■and from the possibility of failures owing to the use of an inferior or badly 
prepared drug, we cannot but conceive that to discard it as utterly in- 
decisive, would be indulging a spirit of irrational incredulity, leading to 
the rejection of any amount of merely presumptive proof. But assuredly 
under circumstances like these, granting that the efficacy of the means 
is only problematical, none should hesitate to employ measures so simple 
in their application, and so safe in their consequences. The failure to 
avail ourselves of the prophylactic influence of belladonna, we cannot now 
but regard as a violation of those sacred obligations, which force us to 
leave nothing untried which may contribute so largely to the mitigation, 
or eradication, of one of the severest inflictions of the hand of God." 

Prof. Stille, after a complete review of all the evidence that has been 
collected upon this subject (Therapeutics, vol. i, p. 788), concludes as 
follows : " We feel bound to express the conviction that the virtues of bel- 
ladonna as a protection against scarlatina are so far proven, that it be- 



MEASLES. 723 

comes the duty of practitioners to invoke their aid whenever the disease 
breaks out in a locality where there are persons liable to the contagion." 

Dr. Irwin gave it in the following manner. Three grains of the extract 
were dissolved in an ounce of cinnamon- water, and two or three drops of 
the solution given morning and evening, to a child under one year old, 
and one drop more for every year above that age. 

HufelancVs formula, which is the one we have always employed our- 
selves is, according to Rilliet and Barthez, as follows : 

R. — Extract. Belladonna?, gr. iij. 

Alcohol, f£j. 

Aqua? Destillat, f^ss. 

A drop morning and evening for each year of the age of the child. 

In order to purify articles which have been exposed to scarlatina, they 
should be either put in boiling water, or exposed to a temperature of over 
200°, as we have seen that a temperature somewhat below the boiling- 
point of water destroys the activity of the virus. 



AKTICLE II. 

MEASLES, RUBEOLA, OR MORBILEI. 

Definition ; Frequency ; Forms. — Measles are an epidemic and con- 
tagious exantheme, characterized by catarrhal symptoms, continued fever, 
and an eruption, generally on the fourth day, of a crimson rash, in the 
form of stigmatized dots, like flea-bites, slightly elevated, which coalesce 
into irregular circles or crescents. It ends about the seventh day by des- 
quamation. 

The frequencjr of the disease is very irregular in different years, be- 
cause of its epidemic nature. Thus, according to the mortality tables of 
the Board of Health, there have been 22*19 deaths from measles in this 
city during the past sixty years. In five of these years, as will be seen 
by a reference to the table at page 665, there is not a death recorded from 
this cause, while, on the other hand, the annual mortality exceeds 100 in 
eleven years, and 200 in two. During the same period, the deaths from 
scarlatina in this chVf, as already stated, amounted to 13,016. 

Measles are probably a more common though a less fatal disease, and 
attack a larger number of persons than scarlet fever ; thus, during a 
period of fifteen years, we have met with 314 cases of the former to 263 
of the latter. 

We shall describe two forms of the disease ; the regular or rubeola vul- 
garis ; and the malignant or rubeola maligna. We shall afterwards treat 
of its irregularities and complications. 

Causes. — A chief cause of the disease is epidemic influence. Of this 
there can be no doubt, as it is proved by the evidence of all observers. 



724 MEASLES. 

Contagion. — Its contagions nature is universally admitted. This is 
thought to begin with the primary fever, and to continue up to the period 
of desquamation, though some authorities believe that it is also conta- 
gious during the stage of incubation. The precise period at which it 
ceases is not however known. The disease may be carried in.fomites. It 
has been propagated also by inoculation with the blood taken from a pa- 
tient, and with serum obtained from the vesicles which sometimes accom- 
pany the eruption. 

The period of incubation is very difficult to determine, owing to the un- 
certainty as to the date when the disease becomes contagious ; but is usually 
stated as from five or six, to twenty days, or even longer. In the great 
majority of cases, however, the eruption appears in from twelve to fifteen 
days after exposure to the contagion, thus making the duration of the 
period of incubation from nine to twelve days. Thus, in 12 cases where 
we were able to determine with precision the interval between the expo- 
sure to contagion and the appearance of the rash, it was ten days in 1 
case, eleven in 1, twelve in 3, thirteen in 5, fourteen in 1, and fifteen in 1. 
In 108 cases observed by M. Girard, of Marseilles (quoted in Med. Times 
and Gaz., Aug. 21, 1869, p. 225), the eruption appeared as late as the 
sixteenth day only in 3 cases ; in all the others it was developed on the 
thirteenth or fourteenth day, never before the thirteenth, and never after 
the sixteenth. 

MM. Rilliet and Barthez conclude that measles are more frequent, less 
contagious, and have longer incubative and prodromic stages than scarlet 
fever. 

The same authors are of opinion that variola is somewhat more rare, 
rather more contagious, and that its period of incubation and its pro- 
dromic stage are a little shorter than those of measles. 

Measles, like other contagious diseases, rarely occur a second time in 
the same individual. 

Age. — We find by uniting Dr. Emerson's tables with some given by Dr. 
Condie (Dis. of Child., note, p. 100), that the disease appears to be most fre- 
quent between the age of one and two years, for while 395 deaths occurred 
in the second } r ear, only 468 occurred between two and five j-ears of age. 
This does not agree, however, with our own experience, since of 280 cases 
of the disease that have come under our own observation, in which the age 
was accurately recorded, only 36 occurred in the second year, while 84 
occurred between the end of the second and the end of the fifth year. 
This discrepancy depends probably, in part at least, on the greater mor- 
tality of the disease during the earliest years of life, which would of 
course give a larger number of deaths for those attacked in the second, 
than for those in the third, fourth, and fifth years. The cases that have 
come under our own observation occurred as follows. The}^ are stated in 
their order of frequency. In the sixth jqsly, 37 ; in the second, 36 ; in the 
seventh, 35 ; in the fifth, 34 ; in the fourth, 30 ; in the eighth, 27 ; in the 
first, 19 ; in the ninth, 11 ; and then in the eleventh, tenth, thirteenth, 
twelfth, and fifteenth. 

Sex. — It appears to be more common in the male than in the female 



CAUSES — SYMPTOMS. 725 

sex. Of 290 cases that we have seen, in which the sex was noted, 156 
occurred in males, and 134 in females. 

In 1862, Dr. Salisbury, of Ohio (Amer. Jour, of Med. Sciences, July and 
October, 1862), published two elaborate articles, in which he attributed 
measles to the action of the fungus developed on damp, mouldy straw. 
He reported the results of numerous cases in which this fungus had been 
inoculated with the production of a modified form of rubeola, which, 
however, protects the system against a future attack of true measles ; and 
also instances where measles had broken out in camps where damp straw 
was used for bedding. 

A complete examination of this question, embodying the evidence of 
Dr. Woodward {Camp Diseases of the U. S. Armies, Philadelphia, 1863), 
and the experiments of Dr. C. E. Smith, and one of ourselves, will be 
found in a paper by Dr. H. C. Wood, Jr., in The American Journal of 
the Medical Sciences, October, 1868, p. 342. 

The results of the inoculation of nearly 50 cases, prove that in nearly 
every instance, the introduction of the straw fungus into the system is 
entirely without effect ; and that in the few cases where any symptoms 
have followed, they have not been those of true rubeola, nor have they 
protected the sj^stem from an attack of genuine measles. 

In regard to the occurrence of camp measles also, Dr. Woodward re- 
marks, that it prevailed almost exclusively in regiments raised in the 
rural districts, while those from cities and towns were more or less com- 
pletely exempt ; and that the inevitable inference from this, confirmed 
by personal inquiry, is that the recruits from the country had generally 
escaped the disease before their enlistment, while those from towns had 
usually suffered from it at some previous period ; a condition of things 
entirely at variance with the idea that the straw fungus is the veritable 
cause of measles. 

Symptoms; Course; Duration. — Regular form of the disease. — Stage 
of invasion. — Measles begin with languor, irritability, sometimes chilli- 
ness, anorexia, aching in the back and limbs, fever, thirst, headache, and 
various signs of irritation of the mucous membrane of the eyes, nose, 
fauces, and larynx. 

The chilliness or horripilations which are mentioned by almost all 
writers are difficult to appreciate in children. We have seldom known 
the child itself to complain of them, but upon inquiry of the mother or 
nurse, have sometimes been told that they had observed some coolness 
of the hands or feet, or a disposition to keep near the fire, and a desire 
for additional clothing. These, therefore, are not important symptoms. 
Neither is the aching in the back and limbs, as it is seldom complained 
of, and can be ascertained in the older only by close questioning, or sus- 
pected in the younger by their complaining when they are moved. Fever 
is very rarely absent. It almost ahvays comes on with, or very soon after 
the other prodromes, but in rare cases does not begin until the second 
day. It is almost invariably continued, after it once begins, except that 
it remits somewhat about daylight and in the early part of the morning, 
to become exacerbated again in the after-part of the day. Its intensity 



726 MEASLES. 

increases, and the remissions become less distinct and shorter, as the 
time for the appearance of the eruption approaches. The pnlse is in- 
creased in frequency, force, and volume, but rarely attains the same 
rapidity as in scarlet fever. At the same time the skin becomes warm 
and dry, the face is generally flushed, and there is considerable restless- 
ness and irritability at first, often passing into quiet and drowsiness as 
the eruptive point approaches. The fever is accompanied by thirst, par- 
tial or complete anorexia, and generall}- by headache, which is frontal, 
and often complained of by children old enough to give an account of 
their sensations. 

Vomiting occurs sometimes, but not as a general rule. The catarrhal 
symptoms commence with, or may even precede the fever. They con- 
stitute the most characteristic symptoms of the disease, and indeed the 
only ones by which we are able to distinguish it with any certaint}' in the 
first stage. They are irritation and redness of the conjunctiva, especially 
that of the eyelids, lachrymation, suffusion of the eyes, sensibility to 
light, stuffing of the nose, cor} T za, sneezing, slight soreness of the throat, 
cough, some constriction of the thorax, and slight dyspnoea. The state 
of the eyes and nose are very important as signs of the disease. The 
above s3 T mptoms are not alwaj^s present in the same degree, being very 
strongly marked in some instances, in others less so, and in some rare 
cases, absent. They are important, because there are few cases of ordi- 
naiy cold in which they are present to the same extent, or if so, the 
accompanying general symptoms are slight compared with those of 
measles. We have rarely known the faucial affection severe enough to 
elicit complaints, and never to produce difficulty of deglutition. It con- 
sists generally only of slight redness of the tonsils, soft palate, and 
phaiynx, which is most strongly marked about the time that the eruption 
makes its appearance. There is usually also some enlargement of the 
glands behind the jaw, and even of the cervical lymphatics. The cough 
usually appears on the first day. Infrequent and slight at first, it be- 
comes more troublesome as the case progresses, until it assumes, on the 
third or fourth day, a character which is peculiar, and which may often 
lead to a suspicion as to the true nature of the attack. It is laryngeal, 
hard, dry, rather hoarse, and occurs generally in short paroxysms. Ex- 
pectoration, if present at all, is slight, and consists of a clear, viscid 
mucus. At the same time the voice is often hoarse. 

The tongue is usually white and somewhat furred ; the bowels remain 
in their natural condition, or there may be slight constipation or diarrhoea. 
Constipation is most frequent, according to our own experience. The 
drowsiness, to which we have already alluded, often exists during the 
first stage. We have noticed it in a great many cases. The child, if un- 
disturbed, sleeps quietly for many hours, or for the greater part of one 
or two da}^s, waking only from time to time to ask for drink, and then 
sinking off to sleep again. The symptom is not alarming, unless it be 
connected with others which indicate local disease, or unless it pass into 
coma, or alternate with marked delirium. Other nervous symptoms which 
sometimes occur, especially when the fever is violent, are restlessness, 



SYMPTOMS. 727 

irritability, occasionally delirium at night, and, in var}^ rare cases, con- 
vulsions. Of 167 cases observed by Rilliet and Barthez, the latter symp- 
tom appeared in the first stage only in one, and was then confined to the 
eyeballs. We have met with convulsions in 5 out of 314 cases, at the 
beginning of the eruption, and in one, of which we shall not now speak, 
at the close of the eruption. In one of the cases the convulsions occurred 
on the first day, in a bo}' five years of age, of nervous temperament, and 
who bad had several convulsive attacks during the process of dentition. 
The convulsions were general, but slight ; they lasted only a short time, 
and were not followed by any bad consequences. In the second case the 
sickness began with fever, drowsiness, tremulous movements of the hands, 
delirium, and in a few hours a slight general convulsion. On the second 
day there were two attacks of convulsions, both, however, slight. The 
other symptoms continued as before. On the third day the child was 
better, the fever having diminished, and the nervous symptoms in great 
measure disappeared. On the fourth, fifth, and sixth days, the fever re- 
turned, and on the middle of the sixth da} T , a full measles rash made its 
appearance. There was no recurrence of the nervous symptoms, and the 
case ended favorably. The third case occurred in a boy between seven 
and eight } T ears old, of nervous and impressible temperament. The con- 
vulsive seizure took place just as the rash was coming out ; it was very 
slight, and lasted not more than one or two minutes. In the fourth case, 
in a boy in the second year of life, who had already had three convulsive 
attacks from other causes, showing thereby a manifest predisposition to 
that kind of disorder, the convulsions occurred as in the previous case, 
just at the coming out of the eruption. In this case also the convulsions 
were slight, lasting only a few minutes. In neither of these two cases 
were the convulsions followed by dangerous symptoms. In the fifth and 
last case, the convulsions, as in the two preceding examples, occurred 
just as the rash was appearing ; they were very slight, and were followed 
by no serious consequences. The subject of this case was a girl between 
seven and eight years old, who had previously had an attack of convul- 
sions produced by a severe febrile reaction occasioned by simple angina, 
and another attack, caused by indigestion. 

MM. Guersant and Blache {Diet, de Med., t. 27, p. 658) mention another 
• initial symptom, which has sometimes enabled them to recognize the ap- 
proach of measles before the eruption. This is a peculiar redness, a rose- 
colored punctuation, of the roof of the mouth, soft palate, and uvula, dif- 
fering from that of scarlatina. We have observed this symptom ourselves 
in a few cases, but, as we have also seen it occasionally in roseola, doubt 
whether it is much to be relied upon. 

M. Girard (loc. cit.) states that the early diagnosis may be aided by 
the fact, that a red papule appears near the free border of the velum palati 
several days before the appearance of the eruption. 

The duration of the initial stage is generally from three to four days. 
In a large majority of the cases that we have seen, the eruption has begun 
to appear in the course of the fourth day. This stage may, however, last 
only one or two days, or be prolonged to five, six, or seven, and accord- 



728 MEASLES. 

ing to Guersant and Blaclie (loc. cit., p. 659), it lasted in one case, with 
all the characteristic symptoms, fifteen da}^s. In a case that occurred to 
oiie of ourselves, the subject of which was a girl between one and two 
years old, the eruption, owing no doubt to the presence of severe general 
bronchitis, did not make its appearance until the ninth day of the sickness, 
and even then came out slowly and with much difficult}'. The disease 
was known to be approaching from the fact that another child in the 
house had just recovered from an attack. In another case, in a girl be- 
tween twelve and thirteen years of age, the eruption began on the fourth 
day of the sickness, but was so faint and indistinct that we could not, 
until the sixth day, feel sure that it was a measles-rash. Even after this 
the eruption continued pale and insufficient until the seA^enth day of the 
eruption, when it was out fully and completely. 

Second Stage, or that of Eruption. — The eruption generally appears 
some time in the course of the fourth day, showing itself first on the chin 
or cheeks, or some other part of the face, and extending gradually to the 
neck and trunk, and finally to the extremities. It is often completed in 
from twenty-four to forty-eight hours. It begins in the form of distinct 
spots, not unlike flea-bites, of a more or less bright rose or crimson color, 
verging sometimes towards a deep red, of a roundish shape, with irregular 
edges, and of different sizes, varying between half a line and three lines 
in diameter. When fully formed they constitute true papules, which are 
felt to be slightly elevated and firm to the touch, with broad, flat summits. 
When pressed upon, their color disappears, to return rapidly when the 
pressure is removed. Distinct and scanty at first, the spots or stig- 
mata soon become more numerous, and arrange themselves into clusters 
of an irregularly cresceutic or semilunar shape. The number of these 
clusters and the consequent general tint of the skin, depend upon the 
amount and intensity of the eruption. In very mild cases, or when the 
eruption is imperfect, the clusters of papules are few in number, and they 
are separated by large portions of healthy skin. In severe cases, on the 
contrary, the patches are so numerous, and coalesce so closely, that the 
skin assumes a general deep-red tint. Occasionally in these severe eases 
minute vesicles form on the summit of the papules. Yet it ought to be 
remarked that it can be observed on close examination that the papules 
never run completely into each other, so as to form a continuous red sur- 
face, unless it be over very small spaces and on certain parts of the sur- 
face, more particularly the face. 

The fever does not diminish when the eruption makes its appearance, 
and it sometimes augments. The skin retains its heat ; the irritation of 
the eyes continues and is sometimes very severe; the nostrils are dry 
and incrusted, or there is coryza, and in some few cases epistaxis. The 
face is at the same time flushed, independently of the eruption, the red 
color of the skin being observable in the intervals between the papules, 
and it looks swelled and turgid, from tumefaction of the cheeks and par- 
ticularly of the eyelids. The cough continues, and is loud, hoarse, and 
frequent in most cases, but in others short, scarcely hoarse, and but 
slightly marked. The voice is usually but not always a little hoarse. 



SYMPTOMS. 729 

The respiration is slightly quickened in regular cases, but generally very 
little beyond the natural rate. The tongue is covered with a yellowish 
or whitish fur in its middle, while the edges and tip are clean and red. 
It remains moist and soft unless some complication occurs. The tonsils, 
soft palate, and pharynx, present considerable redness, without tumefac- 
tion. The abdomen commonly remains natural, though in some few cases 
there is slight soreness over its whole extent or in the iliac fossae. Slight 
diarrhoea often occurs at this time. It seldom lasts more than from one 
to three days. In other cases the stools are natural, or there may be 
moderate constipation. The anorexia and thirst continue up to the stage 
of decline. About the time of the appearance of the rash there is often 
considerable restlessness, anxiety, starting and twitching in sleep, slight 
delirium, and in children old enough to describe their sensations, com- 
plaints of headache. The strength of the patient is not decidedly af- 
fected in most of the cases. 

The urine during this stage is scanty, of dark-yellow color, and not 
rarely contains a trace of albumen. 

Stage of Decline and Desquamation. — The disease having reached its 
height in the course of the sixth da}~, the second of the eruption, it re- 
mains nearly stationary for one or two da}~s longer, and begins to subside 
about the seventh or eighth of the disease, or third or fourth of the erup- 
tion. The eruption fades first on the face and neck, and has often very 
much or wholly subsided on those parts while it is still vivid on the ex- 
tremities. The papules lose some of their color, become less prominent, 
diminish in size, and when pressed upon do not disappear entirety as 
the}* did at first, but leave a dull or yellowish stain behind. A little later 
they assume a dirty yellow or copperish tint, which does not disappear 
under pressure, showing that a slight ecchymosis has taken place into 
the substance of the derm. These stains continue a variable length of 
time, and are finally removed hy absorption. As the eruption disappears, 
a slight furfuraceous desquamation takes place in a considerable number 
of the cases, but not by any means in all. This begins usually about the 
face, and may either be limited to that part, or extend to other portions 
of the body. It is seldom general, however, and is often scarcely notice- 
able. It occurs between the eighth and eleventh days of the disease, or 
fourth and seventh of the rash. 

From the moment the eruption passes its highest point of intensity, 
and begins to decline, the other symptoms do the same. The pulse fast 
loses in frequency, and regains its ordinary characters. The heat of skin 
passes away, often with considerable perspiration, but sometimes with 
gentle moisture only. The various catarrhal symptoms subside ; the 
cough is less frequent, loses its hoarseness, becomes softer, and gradually 
ceases. The expectoration, if present, now becomes more copious and 
thinner, and presents nummular masses of muco-purulent matter floating 
in a clear, watery fluid. The tongue cleans off; appetite returns ; thirst 
ceases; the restlessness and irritability disappear; and the child returns 
to its ordinary condition of health. 

Temperature. — According to the observations of Ringer (Beynolds's 



730 MEASLES. 

Syst. of Med., vol. i, art. Measles), the highest temperature reached in 
ordinary cases is about 103° F. If it rises above this it indicates a severe, 
if it continues below this, a mild, attack. The temperature presents the 
diurnal variations usual in fevers, until the close of the disease, when it 
suddenly declines. The duration of measles, measured by the tempera- 
ture, varies considerably; the decline of the fever occurring in some cases 
on the fourth day, in others not until the eighth or tenth day. 

Irregularities of the Disease. — Under this term we shall describe 
only the anomalous s} T mptoms of the disease, which occur independently 
of complications. Those which are produced by the latter causes will be 
fully treated of when we come to consider the subject of the complications. 

In some cases, the symptoms of the prodromic stage are so slight that 
they pass almost unobserved, and the child is scarcely thought to be sick 
until the rash makes its appearance. In others, owing to some peculiarity 
of the temperament, or to the state of the constitution at the time, they 
are much more severe than usual, or some one symptom may be in excess. 
In one case that came under our own observation, in a girl seven years 
old, the nausea and vomiting were very distressing, and were accompa- 
nied by the most intense frontal headache. She complained precisely as 
children generally do with tubercular meningitis, and was, moreover, 
extremely restless, and at night delirious. Nevertheless, the eruption 
came out on the fourth day, and was perfectly regular in its characters 
and course; the unpleasant symptoms ceased from that moment, and the 
patient recovered without any further bad symptoms. We have already 
spoken of five cases accompanied by general convulsions at the com- 
mencement of the first stage. The course of the disease in the subse- 
quent stages, was regular in all respects. In two other cases, in girls, 
sisters, seven and nine years old respectively, of highly nervous tempera- 
ment, the headache in the first stage was so intense as to require the 
application of leeches for its relief; yet the disease was regular in its 
other characters. 

The eruption presents various irregularities which ought to be noticed. 
It has already been stated that the amount of the rash varies according 
to the severity of the case, although in other respects regular. Some- 
times the papules are comparative^ small in size and few in number, and 
consequently, the clusters in which they are arranged have considerable 
spaces of healthy skin between. When this is the case, the stigmata are 
usually rough, lighter in color, and from this circumstance and the fact 
that the spaces between the clusters are large, the general tint of the 
skin is much less deep than in severer cases, in which the opposite of 
these characters prevails. In some of the mildest cases, the amount of 
eruption upon the extremities has been very small, and after forming, it 
has very rapidly, in the space of a night, faded to such a degree as to 
seem almost a retrocession. But as this sudden disappearance has not 
been accompanied or followed b} T dangerous S3 T mptoms, it is clear that it 
was dependent simply on the mildness of the attack. In such instances 
the general symptoms have always been slight, and the whole duration 
of the sickness shorter by two or three days than in severer cases. At 



SYMPTOMS. 731 

times the order of appearance of the eruption is reversed, and the papules 
appear first on the trunk, thence spreading to the face. 

We have already described the dull yellowish stains which remain after 
the papules have faded. These stains sometimes assume, in malignant 
cases, a livid or purplish hue, from the occurrence of passive hemorrhage 
into the tissue of the derm. They may, however, assume a dark and 
purpureous appearance, without any malignant or dangerous symptoms 
whatever. This happened in a family in which one of us attended 
seven cases of the disease in 1845. In three of them (boys of 10, 5, and 
1 year old, respectively), the eruption, which was copious and regular in 
all, became in a single night, at the moment of decline, of a dark brown 
or light purple hue. The spots did not disappear at all under pressure, 
and were evidently formed by true ecclrymoses. The general symptoms 
were all favorable. The only peculiarity to be observed was that the 
fever had disappeared very suddenly, and that the extremities were 
slightly cooler than natural. The convalescence was as usual, except 
that the ecchymotic spots disappeared very slowly and gradually. We 
have, since the above-named period, seen a great many similar cases, but 
in none have the symptoms been attended or followed by any evil conse- 
quences. 

Several authors describe a form of measles without eruption. They 
state that during the epidemic prevalence of the disease, some children 
present all the catarrhal and febrile symptoms, without the eruption, and 
that they are protected against future attacks. The last assertion, at 
least, must be very difficult to prove. For our own part, we have never 
met with such cases, and should we ever seem to do so, would certainly 
not call them measles, lest by so doing the parents might be induced, on 
future occasions, to expose the child unnecessarily to the disease, when, 
should any evil consequences follow, they might justly question the wis- 
dom of the physician's advice. 

Willan and other authors have described another variety of the dis- 
ease, to which is applied the term rubeola sine catarrho, or measles with- 
out catarrhal symptoms. Such cases are said to present no catarrhal 
sjnnptoms whatever, and little or no febrile reaction. They are stated, 
moreover, to occur generally during the epidemic prevalence of measles. 
Most authors agree that this form does not protect the constitution 
against the true disease, and some regard it only as an eruption resem- 
bling measles, dependent upon gastric disorder. Our own opinion is 
that such cases, of which we have seen a considerable number, are nothing 
more than examples of roseola. The entire absence of catarrhal s} T mp- 
toms and of fever, or their very slight character, the short duration of 
the cases, and the little constitutional disturbance exhibited by the pa- 
tient, all serve to convince us that they cannot be attacks of true measles. 
We recollect three such cases in particular, which, had they been accom- 
panied by cough and fever, we should certainly have called measles. 
The}^ all occurred in infants. The rash was preceded for two or three 
days by feverishness, uneasiness, restlessness during sleep, and slight 
diarrhoea, after which the eruption suddenly made its appearance and 



732 MEASLES. 

covered the whole integument within twenty-four hours. There were no 
catarrhal symptoms whatever. At the same time the febrile symptoms 
disappeared, and the children seemed quite well. The eruption never 
lasted over fort} T -eight hoars, and disappeared without leaving a trace 
behind. The}^ were, no doubt, cases of roseola. 

Rubeola Maligna. — This form may occur either as an epidemic or 
sporadic affection. Generally, however, it prevails as an epidemic, and 
depends upon some peculiarity which it is impossible to understand. The 
few sporadic cases which are met with, may be traced generally to some 
vicious state of the constitution of the individual, or to the unfavora- 
ble hygienic conditions in which he is placed. The symptoms assume 
ataxic or adynamic characters, which give to the case the features of 
the typhoid type of disease. The} T ma}^ make their appearance in the 
prodromic, or, as happens more frequently, not before the eruptive 
stage. When the}^ begin in the first stage, the case is marked by great 
frequency and feebleness of the pulse ; by prostration ; by unusual dysp- 
noea and oppression ; and especially by greater violence of the nervous 
symptoms, as delirium or stupor. Sometimes, even in this stage, petechias 
make their appearance, and there is lividity and soreness of the fauces, 
with discharges of dark blood from the nostrils, and sometimes profuse 
and exhausting diarrhoea or dysenteric discharges. When the time for 
the eruption to appear arrives, this comes out slowly and imperfectly, or 
irregularly, and generally assumes a livid, purplish, or blackish color, 
owing to the passive exudation of blood into the papules, and hence the 
name sometimes given to such cases, of Rubeola Nigra, or black measles. 

This form of the disease assumes, in fact, many of the features of pur- 
pura hemorrhagica. The patient may die of exhaustion, of congestion of 
some important organ, as the brain or lungs, of the diarrhoea or dj'sentery 
which sometimes complicate the disease, or finally of the hemorrhages 
which occur in consequence of the dissolved and fluid state of the blood ; 
or he may, after a severe struggle with the disease, recover his health. 

Complications and Sequelae. — MM. Rilliet and Barthez begin their 
chapter on the complications of the disease with the following excellent 
remarks. " Rubeola manifests itself hj an inflammation or inflammatory 
fluxion upon the skin and mucous membranes. The regular course of 
the disease depends upon the conservation of a due equilibrium between 
these two kinds of fluxions. That which is seated in the skin ought in 
general to predominate : if the equilibrium be destroyed by any cause 
whatever, whether accidental or inherent to the disease, and should the 
predominance of the inflammation take place in the mucous membranes, 
there will result a phlegmasia of some one of those tissues. 

" It is easy to foresee, by attention to these circumstances, that the in- 
flammatoiy complications of measles will be most apt to fall upon the 
mucous membranes, and that broncho-pneumonia, pharyngo-laryngitis, 
and intestinal inflammations will be the most frequent of all." 

Bronchitis and Pneumonia. — These constitute by far the most frequent 
and important complications of measles. In 167 cases, MM. Rilliet and 
Barthez met with 24 cases of bronchitis, 1 of pneumonia without bron- 



COMPLICATIONS. 733 

ehitis. and 58 of lobular broncho-pneumonia. This statement shows how 
very large a proportion of the cases of measles occurring in the Children's 
Hospital at Paris, became complicated in the course of the attack. The 
proportion in private practice is much smaller, since in 314 cases we have 
met with only 24 of bronchitis, and 6 of lobar pneumonia. These are, 
however, in private practice, according to our experience, much the 
most important of the complications likely to occur. Of six deaths which 
occurred in the 314 cases that we have seen, 3 were caused by bronchitis. 

The time at which these different complications make their appearance 
is important. They may occur during the initial stage, early in the erup- 
tive stage, during the decline of the eruption, or after the eruption. The 
most common period for their occurrence is the initial stage. It is diffi- 
cult or impossible to ascertain their causes in a great many cases. In 
some instances they depend evidently upon cold. Age has some influence 
upon their production, as bronchitis is most apt to occur in young chil- 
dren, whilst lobar pneumonia attacks those who are older. 

The physical signs of these affections are the same as when they exist 
in the idiopathic form. The rational signs are increase of cough, which, 
instead of being merely laryngeal, becomes deeper and either pneumonic 
or catarrhal, and dyspnoea, which is sometimes excessive, the number of 
respirations mounting to 40, 50, and, in severe cases, to 60 and 80. The 
pulse is more frequent than in regular measles, and in very bad cases be- 
comes rapid and small ; the skin is hot and dry ; the face is pale and 
anxious in severe cases, in which the eruption does not appear ; and the 
child is generally restless and irritable, with broken irregular sleep, or in 
the most violent cases, it is dull and soporose. In two of the fatal cases 
that came under our observation, convulsions occurred. It should be re- 
marked, however, that in one, the patient, a boy only nine months old, 
was laboring under an attack of hooping-cough, and that it was in one of 
the paroxj-srns of that malady that death took place. In the other case, 
that of a boy eighteen months old, the convulsions occurred first on the 
day of eruption, and then ceased, to recur again the third day afterwards. 
The bronchitis dated from before the appearance of the eruption, and 
was no doubt the cause of the convulsions and death. 

When a pulmonary complication begins in the prodromic stage, it al- 
most alwa3's modifies the eruption in some manner, either retarding or 
rendering it irregular or imperfect. When it dates from the second stage, 
it may cause a partial or complete retrocession of the eruption. We have 
known the eruption to be retarded several days, so as not to come out 
until the fifth, sixth, or even ninth. When the rash does appear, whether 
at the usual period or later, it is evidently with difficulty. It is pale and 
scanty, or abundant on one part of the body, and scanty on another, or 
it appears and disappears alternately. At length it either comes out 
fully, and the threatening symptoms pass away, or the eruption lasts the 
usual, or nearly the usual length of time, in its pale and imperfect con- 
dition, and the child recovers slowly and gradually from the complica- 
tion, which has become the most important part of the sickness ; or, in 
fatal cases, the symptoms grow worse and worse, and the child dies after 



734 MEASLES. 

a few days, or a longer time, according as the inflammation assumes the 
acute or chronic type. 

Whenever it is observed in a case of measles, that there is more drow- 
siness or irritability than usual, or that the pulse is more frequent or 
stronger than it ought to be, it becomes important to ascertain carefully 
the state of the respiration. If this be accelerated, the thorax ought to 
be examined with strict attention by auscultation and percussion, to dis- 
cover whether there be not some pulmonic inflammation at work, likely 
to convert the disorder from a mild one, as it almost always is when un- 
complicated, into one dangerous to life, which it will assuredly become, 
should any pulmonic complication be allowed to steal unawares upon the 
patient. 

The prognosis of the pulmonic complications of measles would appear 
to be very unfavorable in hospitals for children, since Rilliet and Barthez 
state that scarcely one patient in four or five recovered. Of the 30 cases 
that we have seen, we have already stated that 3 died of bronchitis, and 
if we recollect that one of these was complicated also with pertussis and 
morbid dentition, it will be seen that the prognosis is, as might be ex- 
pected, vastly more favorable in private than in hospital practice. 

There is, however, a tendency, especially marked in delicate, strumous 
children, for the inflammation of the bronchial mucous membrane to be- 
come chronic, in which case the cough may persist for years, at times in- 
termitting, but returning after the slightest exposure, and particularly 
in cold, clamp seasons of the year. 

Laryngitis is a common complication of the disease. The authors just 
quoted, met with it in 35 of their 167 cases. It occurred in 8 of the 
314 cases that came under our observation. It is often accompanied by 
pharyngitis. 

Autopsies show that the laryngitis may be slight, severe, or accom- 
panied with pseudo-membranous exudation. The inflammation may be 
simple, consisting merely of different degrees of redness, or of redness 
with thickening and softening of the mucous membrane ; it may be more 
intense and accompanied by ulcerations or erosions ; or, lastly, it may be 
associated with an exudation of false membrane. 

The symptoms of this complication will depend upon the form the in- 
flammation assumes. It is unnecessary to describe them here, as they 
are the same as those of the idiopathic affection, which has already been 
fully treated of. 

The occurrence of laryngitis exerts but little influence on the rash, par- 
ticularly as it almost always appears during the decline of the latter. It 
is seldom fatal, unless it assume the pseudo-membranous form. The 
eight cases that came under our observation were attacks of the simple 
disease, and they all recovered. 

Inflammation of the Intestines. — According to Rilliet and Barthez, 
lesions of the intestinal mucous membrane are the most frequent com- 
plications, after pulmonary affections. About a third of their cases pre- 
sented at the autopsy er} r thematous inflammation of the mucous mem- 
brane ; a fifth offered follicular entero-colitis, a seventh ulcerative inflam- 



COMPLICATIONS — INTESTINAL INFLAMMATION. 735 

mation. and a fourth softening. Some presented several of the lesions 
united, and in a few no lesion was found, though the symptoms of entero- 
colitis had existed during life. We give these data from the above 
authors, not because they apply to private practice, but merely in order 
to show what are the tendencies of the disease, when disposed from un- 
favorable hygienic conditions to take on complications. We have met 
with only seven instances of intestinal inflammation in the 314 cases that 
have come under our own observation. Four of these occurred in the 
same family, in children of seven, five, three, and one year old respec- 
tively. They were cases of entero-colitis, accompanied, in two, with dys- 
enteric symptoms, and all made their appearance towards the close of 
the disease. The three remaining cases were attacks of ctysentery, one 
of which was very severe, the stools amounting to twenty in the day, 
while the other two were much less so. 

The intestinal complications may appear during the initial stage, or on 
the day of eruption, but if not at one of those periods, they are most apt 
to occur during the decline of the rash. The slight cases, constituting 
the common diarrhoea of the disease, generally begin early, whilst the 
grave cases usually date from a later period of the disease. The causes 
of these complications seem to be various exciting agents acting upon a 
mucous membrane predisposed, by the nature of the disease, to inflam- 
matory action. ' These agents are said to be, generally, improper food, 
giving rise to indigestions ; and the too early use of purgative remedies, 
and laxatives. In the cases observed by ourselves, it was impossible to 
detect the causes. 

The symptoms are more or less abundant diarrhoea, and in some, but 
not all the cases, sensibility with tumidity and tension of the abdomen. 
This complication does not exert much influence upon the measles, which 
usually pursue their regular course. Sometimes, however, it occasions 
an aggravation of the febrile symptoms, and, when of a grave character, 
may no doubt interfere with the regular progress of the eruptive disease. 

According to Rilliet and Barthez, this complication was very seldom 
the only, or even chief cause of a fatal termination. Scarcely five or six 
of all that they observed, could be considered as of that kind. It in- 
creases verj T much, however, the danger of the pulmonic attacks, for the 
latter are much less serious, so long as they exist alone, while so soon as 
intestinal inflammation is added to them, they become almost necessarily 
fatal. The seven cases that we met with recovered under simple treat- 
ment. 

In a considerable number of cases, a slight diarrhoea, to which we have 
already referred as a common event in measles, occurred, but only in the 
seven above-mentioned did it amount to a serious complication. 

In one case that came under our observation, in a girl between five and 
six years old, fatal cerebral symptoms, due either to congestion of the 
brain or uraemia, occurred just as the rash was disappearing. There was 
no evident cause whatever for this accident. There had been no impru- 
dence either as to diet or exposure. The child was, however, of a tuber- 
cular family, the mother having at this very time tubercular disease of the 



736 MEASLES. 

lungs. The eruption had come out well and properly, and continued to do 
so on the second day without any irregular or threatening symptom. On 
the third day of the eruption this began to decline, and the child had an 
attack of spontaneous vomiting, but continued through the day cheerful 
and pleasant. The night of that day she was restless and feverish, and 
wanted much drink. On the fourth day she was drowsy and heavj^, and 
complained of her head. We saw her first in the evening of this day. She 
was then very dull and heav}^, scarcely answering questions, and protrud- 
ing the tongue slowly and after much urging. She had some little, but 
not a troublesome cough. Careful examination revealed no disease of 
the thoracic organs. The respiration was natural, and the pulse full and 
verjr frequent. On the morning of the fifth day the patient was comatose, 
neither answering questions nor protruding her tongue. In the course 
of the day there were some irregular convulsive movements. In the 
evening the right arm was rigidly flexed at the elbow, and the left one 
stiffly extended. The patient died that night. 

In another case death occurred from sudden effusion of serum into the 
internal cavities, caused apparently by the existence of an excessively 
hydrsemical state of the blood, or possibly connected with albuminuria, 
which had been allowed to come on gradually, without any attempt on 
the part of the parents to seek a remedy during the slow approach of 
this condition of the circulating fluid. The case occurred in a boy in the 
second 3 r ear of his age, and who had a phthisical mother. The attack of 
measles took place in the last week of January, 1852, and was regular, 
and not, according to the account of the parents, we not having seen the 
child, at all severe or dangerous in any respect. After the attack was 
over, however, and though he was running about the house as before, he 
continued to look more and more pale and sickly until the evening of 
February 25th, when suddenly after 11 p.m., he was seized with fever, 
and became very restless. On the following day, at 9 a.m., we saw him. 
He was then extremely pallid, and very drowsy and heavy ; the breath- 
ing was rapid and oppressed, the pulse very frequent, and the skin hot 
and dry. He was evidently dropsical, as both the face and hands, and 
the feet also, were purled, smooth, and doughy. The bowels had not 
been opened the previous night. In the evening the pulse was 170; the 
skin was still hot, and the breathing very rapid and much oppressed. 
There was scarcely any cough. The percussion was dull over too large 
a space in the precordial region ; the cardiac impulse was obscure, and 
the sounds indistinct and muffled ; there was no bellows-murmur. The 
percussion was dull over the inferior dorsal regions. Xo rale whatever 
was heard. The child died on the following morning at 3 J o'clock. Ten 
minutes before his death he asked for a drink, lifted himself up in bed, 
drank freely, looked around intelligently, and then laid down and died. 
At the autopsy the subcutaneous cellular tissue was found to be infiltrated 
with serum. On puncturing the right pleural sac, there was an immedi- 
ate escape of a clear, straw-yellow serum. There was considerable effu- 
sion in the left pleura also, but less than in the right. The pericardium 
contained at least two ounces of serum, so that it was pushed off to a 



ANATOMICAL LESIONS. 737 

considerable extent from the heart. There was a slight pleuritic adhe- 
sion of the upper lobe of the right lung to the ribs. This was, however, 
evidently of an ancient date. There was no other inflammation of the 
pleura?, and none of the pericardium. Both lungs contained tubercles, 
which were not very numerous, but in the upper lobes of considerable 
size. There was no pneumonia, but both lungs were somewhat congested. 
The heart was larger than usual. In the right auricle there was a rather 
large, and white, but soft concretion, and a smaller one in the right ven- 
tricle. The left cavities presented no concretions. The valves were 
healthy. 

There are several other disorders which sometimes complicate or fol- 
low measles, but as we have already given as much space to this subject 
as the limits of the work will allow, we shall be satisfied with a simple 
enumeration of them. They are otitis, ophthalmia, hemorrhages, gan- 
grene of the cheek or vulva, anasarca, and different cerebral symptoms. 
We will merely add, that measles are supposed by many observers to 
have a special tendency to develop tubercular disease in the system, and 
that it is necessary, therefore, to treat a child showing an}^ predisposition 
to that diathesis, or one born of tubercular parents, with particular cau- 
tion, both at the time of the disease and during the convalescence. It is 
not uncommon for measles to be conjoined with other eruptive diseases. 
We have known it to coexist with scarlatina in two instances, and Dr. Gr. 
B. Wood has met with a fatal case of the same nature. It may be asso- 
ciated, likewise, with variola or with erysipelas ; of the latter we have met 
with one instance. We will mention here that of the whole 314 cases of 
measles that we have observed, 25*7 were simple, and 57. complicated. The 
complications were as follows : bronchitis, 24 ; pneumonia, 6 ; laryngitis, 
slight or severe, 8 ; dysentery, f ; pertussis, 7 ; scarlatina, 2 ; convulsions 
in the early stage of the disease, 5, and in the latter stage, 3 ; keratitis, 
2 ; intermittent fever, 1 ; erysipelas, 1 ; meningitis, 1 ; congestion of the 
brain, 1; serous effusion into the internal cavities, 1. It ought to be ob- 
served, however, that in the above enumeration seA r eral cases are referred 
to twice, and one, a case in which pertussis, bronchitis, and convulsions 
occurred, three times. 

Anatomical Lesions. — It is difficult to ascertain what are the charac- 
teristic lesions of measles, because of the fact that most of the fatal cases 
prove so in consequence of some complication. Some few fatal cases, 
however, of the regular form, and some in which the complication was so 
slight as not to be likely to change the morbid appearances much, have 
led to the following conclusions. 

The lesions present in measles are the following : general congestion 
of different organs, which are colored red from the imbibition of blood 
and sometimes softened. The congestion affects the mucous membranes 
particularly, and imparts to them a reddish or slightly blackish color. In 
some of the cases there is morbid development of the intestinal follicles. 
The most important lesion, however, is that of the blood, which presents 
the appearances common to the class pyrexiae. These are normal propor- 
tion, or diminution, of the fibrinous, with increase of the globular element 

47 



738 MEASLES. 

of the blood. Dr. Copland (Diet. Prac. Med., vol. ii, p. 819) gives the ap- 
pearances in a few fatal cases of malignant measles. They were, soften- 
ing of the tissues and the facilit}- with which the} T were torn ; the presence, 
in some of the cases, of a turbid or sanguineous serous fluid in the serous 
cavities; general congestion of the lungs; dark appearance, and livid or 
purple ecchyinoses of the bronchial mucous surface, of the fauces, stomach, 
and caecum ; engorgement with dark and semi-fluid blood of the veins and 
sinuses of the brain, and of the auricles and large veins; and finally a 
livid and mottled appearance of some parts of the body, with petechia? 
of a dark color. 

Diagnosis. — It is impossible to diagnosticate measles in the first stage 
with any considerable certainty. The existence of the disease may be 
suspected in that period from the appearance of the eyes, from the coryza 
and sneezing, the frequent, hoarse, scraping cough, and the fever, head- 
ache, and thirst. If, in connection with these symptoms, it happens that 
an epidemic of measles be prevailing at the time, or that the child has 
been exposed to the contagion of the disease, the inference becomes still 
more plausible. Nevertheless, any opinion upon this point ought to be 
given with much reservation. 

We have alreacty alluded to the opinion of some authorities, that the 
diagnosis in the early stage is aided b}^ the presence of punctated red- 
ness of the roof of the mouth, or of a red papule on the velum palati. 

After the eruption has come out fullv it is not likely to be mistaken for 
any other disease, unless it be roseola, the rash of which sometimes resem- 
bles that of measles very closely. It may be distinguished, however, by 
attention to the concomitant s} T mptoms, — by the slight degree of fever, 
the more rapid evolution of the rash, and the absence of the peculiar 
catarrhal symptoms in roseola. In the very early stage of the eruption, 
measles may be confounded with variola. A careful attention, however, 
to the size and shape of the papules, which in measles are much larger, 
flatter, less elevated, softer, and without the shott}^ feel peculiar to the 
papules in variola, and the presence of the catarrhal sj'mptoms, will usually 
suffice to distinguish them, even in the earliest stage. In measles also the 
general symptoms persist, or even become aggravated after the appear- 
ance of the eruption, instead of abruptly subsiding as they do in variola. 
A little later, the appearance of vesicles on some of the papules about the 
face in variola, will show the difference still more strongly. The distinc- 
tion between measles and scarlatina has alreacby been drawn in the de- 
scription of the latter disease. It rests chiefly on the much shorter dura- 
tion of the prodromic stage, the greater violence of the anginose symptoms, 
the absence of the peculiar catarrhal symptoms, and the more rapid evo- 
lution of the eruption in scarlet fever ; and lastly, on the differences in 
the two eruptions, observable especially at their first appearance. 

The eruption of typhus fever appears nearly at the same time as that 
of measles, and in their earliest stage the two eruptions often resemble 
each other closely. In typhus, however, there is an entire absence of 
the characteristic catarrhal symptoms. The spots are less elevated; are 
isolated and round, instead of coalescing to form crescentic patches ; do 



PROGNOSIS. 739 

not appear first on the face, but on the trunk or wrists (Ringer) ; more 
frequently become petechial, and last a much longer time. 

When measles are conjoined with some other eruption, the diagnosis is 
to be made out b} T a careful study of the initial symptoms, and of the 
eruption on different parts of the body, for we can generally find well- 
marked patches of the rash peculiar to each on some portions of the sur- 
face. In one of the cases of measles and scarlatina that we saw, the latter 
disease was developed first. The eruption made its appearance in the 
usual form ; on the second day of the eruption, the child was seized with 
hard, hoarse, laryngeal cough, and with redness of the eyes and lachry- 
mation. These symptoms continued three days, at the end of which 
time the scarlatinous rash had disappeared from the face, but remained 
risible upon the trunk and extremities. Characteristic measty papules 
now made their appearance on the face, and pursued their regular course, 
while on the trunk and extremities the measly eruption was never well 
defined, being mixed with and disguised, as it were, by that of the scar- 
latina. In the other case, the measles appeared first and went on regularly 
until the eruption was declining and the general sj^mptoms moderating, 
when suddenly the fever, heat of skin, restlessness, and irritability re- 
turned, and the child was very soon covered with the punctated scarlet 
rash of scarlatina. 

Prognosis. — The prognosis of simple, uncomplicated measles is very 
favorable ; the cases almost always recover without difficultj^. This is 
shown to be true by the following facts. Rilliet and Barthez report 36 
cases of simple measles, of which all but one recovered. Of 257 cases 
that we have seen, all terminated favorably. When, on the contrary, com- 
plications occur, the disease always becomes more or less dangerous, the 
degree of danger depending on the nature of the intercurrent affection, 
and on the h}'gienic conditions in which the patient is placed. Thus, of 
131 cases observed by the above authors, in which some form of compli- 
cation occurred, 89 or about two-thirds proved fatal, while of the 53 com- 
plicated cases that we have seen, only 6 were fatal. It must be recol- 
lected that the cases of the French observers all occurred under the 
unfavorable hygienic conditions of a large hospital, in children of bad 
constitution from congenital or acquired causes, whilst ours were ob- 
served in private practice, where the hygienic conditions are favorable in 
the same degree as they are unfavorable in hospitals. 

The six fatal cases that came under our observation, proved so from 
the circumstances we are about to mention. The first occurred in a child 
nine months old, who was laboring under pertussis when attacked with 
measles. Bronchitis supervened upon the measles, and proved fatal by 
convulsions, which came on during a paroxysm of hooping-cough, two 
weeks after the disappearance of the rubeola. The second case was that of 
a boy, eighteen months old, who was prescribed for by an apothecary from 
behind his counter, until we saw him. The eruption made its appearance 
imperfectly, we were told, and with a convulsion. After this he was very 
restless, and had rapid and difficult respiration and much cough. On the 
morning of the fourth day of the eruption, this had almost entirely dis- 



740 MEASLES. 

appeared, and the child was again attacked with convulsions. We saw 
him shortly after this for the first time, and found him comatose, with 
convulsive movements of the limbs, extreme dj^spnoea, and all the symp- 
toms of extensive bronchitis of both lungs. He died thirtj^-six hours 
from this, as was to be expected. The third was a case of pneumonia in 
a child between one and two years of age, in which the inflammation came 
on as the eruption was fading, and proved fatal, in spite of all that could 
be done, on the eleventh day. The fourth occurred in a boy between 
four and five years old, who appeared to recover perfectly from the measles, 
but was attacked in ten da3 T s with meningitis, and died. The fifth was 
the case of congestion of the brain, alread} T detailed in the remarks upon 
complications, as proving fatal shortly after the decline of the rash. The 
sixth was that of sudden dropsical effusion into the internal cavities, also 
described in the remarks upon complications. 

To conclude, we may state that the prognosis is always highly favorable 
under the following circumstances: when the disease is primary; when 
the initial stage is of the proper duration ; when the eruption begins upon 
the face and extends gradually to the rest of the bod}' ; when the febrile 
movement is moderate ; when the eruption, after increasing for one, two, 
or three days, gradually decreases ; when the cough and other concomi- 
tant symptoms diminish with the fever ; when the cutaneous surface, after 
the fading of the rash, assumes a natural color, and is neither flushed nor 
pale ; when the appetite returns, the disposition to be amused and take 
notice continues, and lastly when the sleep is natural. 

On the contrary, the prognosis becomes unfavorable under the following 
circumstances : when the initial stage lasts longer than usual, and when 
it is accompanied by violent symptoms of any kind, as extreme jactita- 
tion, irritability, dyspnoea, much stupor, coma, or convulsions ; when the 
eruption is irregular in its appearance or course; when the fever does not 
disappear with the eruption, whether it remains violent or assume the form 
of hectic ; when, after the eruption, the face continues deeply flushed or 
becomes very pale ; when the cough, d3 T spncea, or diarrhoea persist ; and, 
lastly, when the child remains weak, languid, dispirited, or irritable. 

It maj' be stated in conclusion, that the prognosis of measles is always 
favorable in proportion to the health of the child at the time of the inva- 
sion, and the regularity with which the disease passes through its different 
phases ; while it becomes unfavorable, though far less so in private prac- 
tice amongst people in esisj circumstances, than in hospitals or amongst 
the poor and wretched, whenever it attacks a child already laboring under 
some disease, and when it becomes complicated with any other malady, 
either local or general. 

Treatment of the Regular, Simple Form. — This form requires, in a 
large majority of the cases, little other treatment than strict attention to 
the hygienic condition of the patient, the use of simple diaphoretics, of 
mild cathartics occasionally, and the palliation of any of the symptoms 
that may chance to become somewhat more troublesome than usual. 

Hygienic Treatment. — The child ought to be confined as much as 
possible to bed in a large, well-ventilated chamber, the light in which 



TREATMENT. 741 

should be somewhat softened. Eveiy precaution should be observed to 
prevent chilliness, while at the same time it is nearly, if not quite as im- 
portant, to avoid overheating the patient, either by excessive clothing, 
or by keeping the temperature of the room too high. In winter, it is well 
to direct the temperature to be maintained at between 68° and 10° F., 
night and day. If this be clone, the child is not apt to take cold, even 
though it be uncovered at times, and jet the warmth is not oppressive. 
"We have often remarked that this temperature is just what it ought to be 
when the room is well ventilated, either by means of an open fireplace, or 
by communication with adjoining rooms; but when, on the contrary, the 
room is heated by a furnace-flue, and not ventilated at all or very imper- 
fectly, the same temperature, as indicated by the thermometer, becomes 
extremely close and oppressive. Under such circumstances, a door into 
an adjoining room, or if this cannot be, one into the entry, ought to be 
kept more or less open, with a screen of some kind between it and the 
child, in order to secure a good ventilation, which is assuredly of the 
very highest importance, and yet to prevent by the screen a current of 
cool air from chilling the patient. The diet during the febrile period 
ought to be very light. It ma}^ consist of milk and water, of arrowroot, 
sago, or tapioca, prepared with milk or water ; or of crackers soaked in 
water, with salt, or some similar food. When the eruption and fever have 
in great measure disappeared, some light broth, either vegetable or ani- 
mal, with dry toast or bread, plain boiled rice, a roasted potato, or ice 
cream, may be added ; and after all the symptoms have ceased, the usual 
diet can be gradually resumed. The drinks may consist of simple water, 
of lemonade, orangeade, gum-water, or flaxseed-tea, with the addition of 
a little sweet nitre ; or of weak infusions of balm, sweet-marjoram, or saffron, 
or cascarilla with a few drops of hydrochloric or nitric acids. They may 
be given in any reasonable quantity, at the temperature of the room. 
Some persons have a great dread of cold water in this disease. We have 
never seen small quantities (half a wineglassful to a wineglassfnl at a 
time) of the coldest water do any harm, and believe it to be useful when 
the fever is violent, and the heat very great. We once, however, saw a boy, 
nine years old, attacked with violent colic and partial retrocession of the 
eruption, after swallowing suddenly a tumblerful of iced-water. The un- 
pleasant symptoms passed off in a few hours, and he had no difficulty 
afterwards. 

The patient should not be permitted to leave the room until a few days 
after the entire disappearance of the disease. It ought to be kept in the 
house until it has regained in some measure its strength and healthful 
looks, as it will scarcely be able to resist exposure before. 

Therapeutical Treatment. — The therapeutical management of the 
regular form ought to be very simple. When the bowels have not been 
opened naturalty for one or two days, it is proper to direct an enema to 
be used, or, if the fever and restlessness are considerable, some mild laxa- 
tive, as a teaspoonful or dessert-spoonful of castor oil, a dessert or table- 
spoonful of syrup of rhubarb, half a teaspoonful of magnesia for older 
children, or less for younger, or some similar remedy, always selecting 



742 MEASLES. 

those which are mild, and giving them in small doses, lest they irritate 
the gastro-intestinal mucous membrane. It is better to give a small close 
and repeat it in four or six hours, or assist it by an enema, than to give 
such a quantity as might produce over-purging, and thus perhaps disturb 
the regular progress of the eruption. The laxative may be repeated from 
time to time throughout the disease, if the bowels are not moved natu- 
rally. After the laxative we may either do nothing, when the case is mild 
and when it progresses favorably, or else give one of the infusions above 
mentioned, or a little sweet spirit of nitre. If the reaction, however, be 
considerable, with much headache, restlessness, and dry, hot skin, we 
would give small doses of antimonial wine and sweet spirit of nitre (from 
one to three or four drops of the former, with ten or twenty of the latter), 
every two hours, and direct a warm mustard foot-bath to be given twice 
a day. Even if the fever be violent, with frequent, strong, and full pulse, 
intense heat of skin, severe headache, and much restlessness, depletion 
in any form is unnecessary, as the symptoms will usually subside under 
the use of the more mild remedies recommended above, or, what we have 
found very useful, the emplo3 r ment of the mixture of citrate of potash and 
opium, recommended at page 205. 

Of the 251 regular cases that we have seen, depletion was employed 
only in 2 : in one a venesection of four ounces in a boy seven years old, 
in consequence of the great violence of the reaction, and not from any 
discoverable local affection ; and in the other, the application of leeches 
to the temples, for intense headache, in a girl nine years old. Under 
the same circumstances a warm bath, given w T ith care, and continued for 
fifteen or twent}' minutes, will be found of great service ; or, a simple 
foot-bath may be used, and repeated three or four times in the course of 
a clay. 

If any of the local symptoms become particularly troublesome, they 
should be palliated by simple treatment. When the cough is very fre- 
quent and hard, it is most effectually moderated by some anodyne, which 
may be given in most cases without any detriment. The only contrain- 
dication to its use is the presence of severe headache or some other cere- 
bral s3'mptom. A mild counter-irritant application to the outside of the 
throat is also useful; we have generally used sweet oil and spirit of 
hartshorn. When the conjunctival inflammation is acute and painful, it 
ma}' be relieved by lotions with simple warm water, milk and water, or 
sassafras-pith mucilage, alone or mixed with rose water. If the headache 
be very violent it can generalty be relieved by the use of a laxative, by 
the occasional use of a mustard foot-bath, or of a sinapism to the nucha, 
and by the application of cold to the head. 

If, at any time during the course of the case, symptoms of exhaustion 
appear, the most nourishing and concentrated food, with alcoholic stimu- 
lants in graduated doses, should be promptly resorted to. 

The malign aw t form of the disease must be treated chiefly with stimu- 
lants and tonics. The most useful are wdne and brand}', quinia, am- 
monia, capsicum, &c. Camphor and opium would be proper, were the 
case attended with severe nervous symptoms. The diet ought to be nu- 



TREATMENT OF COMPLICATIONS. 743 

tritious and digestible, and may consist of milk and bread, light broths, 
and beef tea or essence of beef. 

When local inflammations occur, they may be treated by a few dry cups, 
or by means of counter-irritants, of which the most suitable are mustard, 
spirit of turpentine, or ammonia. Blisters ought to be avoided, as they 
are very apt to occasion dangerous and even fatal sloughing. 

Treatment of the Complications. — Bronchitis, Pneumonia. — The 
mode of treatment of these complications must depend upon the stage at 
which they are developed, and upon the age and constitution of the sub- 
ject. When they occur during the first stage, one of the most important 
points in the treatment is to endeavor to favor the appearance of the 
eruption, and when in the second stage, and the eruption has retroceded 
wholly or in part, the same indication applies with equal force. When 
they appear during the third stage, they are to be treated without any 
regard to the eruption, but always with reference to the fact that the pa- 
tient has just passed through an acute febrile disease, which must have 
weakened in some degree the vital powers. 

It ma} r be stated in general terms, that the treatment proper for these 
local inflammations when the}^ occur as primary affections, is proper also, 
with some reservations, under the circumstances we are now considering. 

Thus even local depletion should be employed only with the greatest 
care, and, indeed, we should recommend in preference the application of 
dry cups, or of sinapisms. 

Purgatives should also be used with caution, on account of the dispo- 
sition to gastro-intestinal irritation which is always present in this disease. 
Our own practice is to employ moderate counter-irritation, in conjunction 
with minute doses of sulphurated antimony and Dover's powder, or a 
mixture containing citrate of potash and syrup of ipecacuanha. When 
in these cases the skin is at all coolish, or bathed with too considerable 
a perspiration, we have found the liquor ammonise acetatis a very useful 
remedy. 

It is universally acknowledged that it is exceedingly important to assist 
nature in throwing out the rash, whenever these complications either pre- 
vent its formation, or cause its retrocession. The true mode of doing 
this is to cure or alleviate the internal inflammation, which is the cause 
of the difficulty. To attain this end the above plan of treatment ought 
to be instituted at once. At the same time, we may greatly assist the ap- 
pearance of the eruption by a persevering employment of counter-irritants. 
The best of these is, we believe, mustard, and in some cases a warm bath. 
The mustard may be used in the form of plasters, poultices, or baths. 
Our own plan in moderately severe cases, is to apply a mustard poultice 
to the interscapular space, and to make use of a mustard foot-bath, two 
or three times a day, while in severe and urgent attacks we direct the 
cataplasm and bath to be renewed every two or three hours, taking care, 
however, to apply the former alternately to the front and back of the 
chest, in order to avoid all possibility of too violent an action upon the 
skin ; the feet and limbs also ought to be carefully watched, to avoid the 
same danger. We have had occasion to observe the great efficacy of this 



744 MEASLES. 

unremitting employment of revulsives, in several severe cases of bron- 
chitis in young children. In some we have depended solely upon this 
treatment, and the use of small closes of ipecacuanha and spiritus Minde- 
reri. In one particularly, which occurred in a child eight months old, 
the attack came on in the first stage. On the fourth, fifth, and sixth 
daj^s, the clyspnoea was excessive, the respiration running up to TO and 80 ; 
the pulse was frequent and small; the skin pale and rather cool; and the 
irritability and restlessness ver}^ great. For a period of twenty-four 
hours, we used the poultices and foot-baths every two hours regularly, 
and gave internally the spiritus Minclereri at the same intervals. Nothing 
else was done. On the sixth day, when one of the poultices was removed 
from the interscapular space, the integument beneath was observed to be 
covered with the measly stigmata, whilst there were none as jet on any 
other part of the surface. From this time the eruption came out freely, 
and the child recovered rapidly. 

The warm bath may be used under the same circumstances. It should 
be given with great care, the child being wrapped in a warm blanket the 
moment it is removed from the water, to prevent the least sensation of 
chilliness. It ma} T either lie for a short time in the blanket, or be wiped 
dry beneath it, and then dressed. 

In some of the cases of bronchitis, there has been profuse secretion 
attended with extensive subcrepitant and mucous rales. In such in- 
stances we have found the internal use of the syrup or infusion of po- 
lygala seneka, with an occasional revulsive, very effectual. 

The diarrhoea which occurs so frequently seldom requires any treat- 
ment. Indeed, unless it indicates evident entero-colitis, or is accompa- 
nied b} r frequent mucous or bloody stools, and by pain and tenesmus, it 
is better not to interfere with it, beyond pajing strict attention to the 
diet. When attended, however, with the S3 T inptoms just mentioned, it 
must be treated by astringents, by opium and ipecacuanha, and b} r the 
application of poultices to the abdomen. The seven cases that occurred 
to ourselves recovered under the use of laudanum enemata, given twice or 
three times a day, the strictest diet, and small doses of Dover's powder. 

Laryngitis, as it occurs in most of the cases, needs but little treatment 
beyond careful avoidance of cold, the use of some mild nauseant, and re- 
vulsives to the neck. It is very seldom of a dangerous character. When, 
however, it assumes the character of pseudo-membranous croup, it must 
be treated with all activity, in the manner described in the article on that 
disease. In only two of the eight cases we have seen, did it appear at 
all threatening, and both of these recovered under the use of emetics and 
moderate leeching of the throat. 

The cerebral symptoms which sometimes occur, must be treated differ- 
ently in different periods of the disease. In the early stage, when they 
last but a short time and do not recur, they require nothing more than a 
warm bath and the use of revulsives. If the} T continue to recur, or are 
followed b}' stupor or other cerebral sjmiptoms, more energetic treatment 
becomes necessaiy. If the child is strong and hearty we ma}^ apply dry 
cups to the back of the neck or temples, and resort to purgatives, re- 



SMALL -POX. 745 

volsives, and cold applications to the head. When the symptoms are 
violent, and when the heat is intense, it has been proposed to use cold 
lotions in the manner recommended in scarlatina. The evidence upon this 
point is not very conclusive, and as we have never used them, nor seen 
them used, nor indeed seen any necessity for a resort to them, we can 
offer no opinion in regard to their value. 

We have met with live cases of convulsions in the first stage. One oc- 
curred in a boy five years old ; the convulsions were slight, lasted not 
more than ten or fifteen minutes, and were followed by no bad symptoms. 
The intelligence of the child returned very' soon afterwards. The only 
remedy used was a warm bath. The other cases have already been de- 
scribed. 

When convulsions occur in the second or third stages, it is very im- 
portant to ascertain whether they are not the result of some local disease. 
Two of the three cases that came under our notice accompanied violent 
attacks of bronchitis. The third was caused by congestion of the brain. 
Here the treatment must be directed against the local disease, if that can 
be detected. When, on the contrary, the convulsions seem to depend on 
nervous irritation, they maj T be treated with baths, revulsives, purgatives, 
and the careful administration of opium, as recommended by S}^denham ? 
Copland, Rilliet and Barthez, and other authors, or of camphor, assa- 
foetida, musk, or Iryoscyamus. If accompanied by intense heat and great 
dryness of the skin, without local complications, cold or tepid lotions 
might also be tried. 

The treatment suitable when any of the complications or sequelae be- 
come chronic, will be found in the articles devoted to the respective dis- 
eases. Bearing in mind the tendency to the development of scrofula or 
tuberculosis after this disease, the most careful attention should be paid 
to all hygienic measures ; and alteratives and tonics, as syr. ferri iodid., 
cod-liver oil, and quinia, should be administered. 



AETICLE III. 

VARIOLA, OR SMALL-POX. 

Definition; Frequency; Forms. — Variola is an epidemic and con- 
tagious disease, characterized by an initial fever, lasting from three to 
four days, and followed by an eruption at first papular, then vesicular, 
and afterwards pustular ; the eruption attains maturity in from six to 
nine days, after which the pustules are converted by desiccation into 
scabs, which fall off between the fifteenth and twent}-fifth days. 

The frequency of the disease varies greatly in different years, because 
of its epidemic nature. It is far less common in childhood amongst the 
middle and upper classes of the community, than either measles or scar- 



746 



SMALL-POX. 



latina, in consequence, no doubt, of the attention paid to vaccination. 
During the early months of 1865 one of us had the opportunit}^ of study- 
ing a severe epidemic which occurred in portions of this city, and we 
have published elsewhere 1 an analysis of thirty cases in children under 
fifteen years of age, observed at that time. Apart from these cases, how- 
ever, we have met with but two cases of the disease under fifteen years of 
age, in a space of fifteen } r ears, whilst during the same period we have 
met with 203 of scarlatina, and upwards of 314 of measles. It prevails to 
a greater extent amongst the poor and destitute classes, who neglect the 
attention to vaccination necessar}?- to preserve children from the disease. 
We abstract from the article already referred to, the following table, 
showing the entire annual mortality from variola in Philadelphia, to- 
gether with the relative mortality during the early years of life, for the 
past twenty years. 

MORTALITY FROM VARIOLA. 



1848, 
1849, 
1850, 
1851, 
1852, 
1853, 
1854, 
1855, 
1856, 
1857, 
1858, 
1859, 
1860, 
1861, 
1862, 
1863, 
1864, 
1865, 
1866, 
1867, 
1868, 



Total, 



Under 


Between 1 


Between 2 


Total of all 


1 year. 


and 2 years. 


and 5 years. 


ages. 


21 


13 


17 


100 


25 


20 


34 


152 


13 


8 


4 


40 


40 


30 


54 


216 


89 


54 


100 


427 


22 


9 


9 


57 


12 


4 


6 


49 


57 


39 


85 


275 


86 


44 


88 


390 


19 


17 


11 


65 


1 


2 


1 


7 








1 


2 


14 


10 


16 


57 


159 


105 


200 


758 


52 


44 


66 


264 


33 


24 


28 


171 


57 


31 


61 


260 


104 


50 


112 


524 


32 


17 


27 


144 


16 


4 


11 


48 











1 



852 



525 



931 



4007 



An inspection of this undoubtedly establishes the fact that whenever 
the contagious principle of variola, favored by some peculiar epidemic 
ntroduced into this community, it finds a large number of 
unprotected subjects who fall ready victims to its attack. 

We shall describe two forms, the regular, including the distinct or 
discrete, and the confluent varieties of most writers, and the modified 
form or varioloid. We shall afterwards treat of the irregularities and 
complications of the malady. 



1 Amer. Jour, of Med. Sci. 



CAUSES — SYMPTOMS. 747 

Causes. — The principal cause of variola is universally acknowledged 
to be contagion. It is generally admitted also that it is propagated at 
certain periods by epidemic influence. 

It is not clearly ascertained at what period of its course the disease 
first acquires the property of infectiousness. Some assert that it is not 
until after suppuration is established. This is, however, to say the least, 
doubtful, and it is best, therefore, to take any precaution that may be 
necessary to prevent the extension of the disease from the moment that 
its real nature becomes apparent. There can be no doubt that the body 
may still impart the disease after death, and that clothes worn by the 
patient retain the contagious principle, unless freely exposed to the air, 
for days, months, and, it is said, even for years. It is also capable of 
infecting furniture or letters, and may thus propagate the disease at any 
distance, and for an indefinite period, by fomites. 

One attack protects the constitution, in the great majority of cases, 
against subsequent contagion. When persons who have once had the 
disease, contract it again, it almost always assumes a much milder and 
less dangerous form. 

The period of incubation, or the time elapsing between the reception 
of the poison and the onset of the malady, varies generally between nine 
and twelve da}-s. It ma}', however, be more or less than the periods just 
mentioned. 

Symptoms ; Course ; Duration. — Regular form of the Disease. — We 
shall describe three stages of the disease: 1. That of the initial or erup- 
tive fever. 2. That of the progress and maturation of the eruption ; and, 
3. That of decline or desiccation. In addition to these, some writers 
make another stage, that of incubation, which includes the period be- 
tween the introduction of the poison into the system, and the appearance 
of the first sj'mptoms. This stage is seldom marked by symptoms suffi- 
ciently characteristic to enable us to detect the approaching disease, and 
in many instances is probabl}' entirety unnoticed by the patient. 

The first stage, or that of initiatory fever, commences generally in chil- 
dren with pains in the bones and loins, and sometimes with rigors or 
chilliness, accompanied with headache, and soon followed by fever. 
Nausea and vomiting often exist from the first, or come on soon after the 
appearance of fever and headache. At the same time there is loss of 
appetite, thirst, and more or less obstinate constipation. The tongue is 
red at the point and edges. One of the characteristic symptoms of this 
stage is pain in the loins, which generally dates from the first or second 
da} T , and which, though varying much in degree, is usually severe. The 
patients often complain also of abdominal pains, which seem to be colick}-, 
and are referred either to the epigastric or umbilical region. 

Fever and headache are the most constant of all the initial symptoms. 
The chilliness and rigors which frequently exist in adults, are not easily 
ascertained in the cases of children, and are therefore much less impor- 
tant. The fever varies greatly as to degree ; the heat of skin is generally 
considerable ; and may be accompanied either with diyness or moisture. 
The pulse is commonly full and frequent. The headache is usually frontal 



748 SMALL -POX. 

and often very severe. In some cases there are strongly marked cerebral 
symptoms, consisting of excessive restlessness and irritability, insomnia 
or somnolence, delirium, and even convulsions. 

The various s3~mptoms just enumerated continue up to the moment 
when the eruption begins to make its appearance, which happens gener- 
ally in the course of the third da}^, though it may occur as early as the 
second, or as late as the fifth, sixth, or even seventh. In severe and con- 
fluent attacks, the eruption, as a general rule, begins earlier than in mild 
and discrete cases. 

Second stage, or that of eruption. — Some time in the course of the third 
day after the invasion of the attack, the eruption usually begins to make 
its appearance in the form of small, isolated, and rounded red specks, 
which soon become projecting and solid, or in other words are converted 
into papules. The papules are from a third to two-thirds of a line in 
diameter, of a more or less vivid red color, which disappears under pres- 
sure, to return immediately when the pressure is removed. They are 
also hard, and feel almost like shot imbedded in the derm. The eruption 
shows itself first on the face, and generally about the chin and mouth, 
and then extends to the rest of the face, to the neck, trunk, limbs, feet, 
and hands. It sometimes happens, particularly in ver}^ young children, 
that the eruption appears first about the genital organs, whilst in other 
cases it is first observed on the lower part of the loins, or upon the thighs. 
The papules increase gradually in size and prominence for one, two, or 
three clays, and, as a general rule, some time in the course of the second 
day of the eruption, undergo a change into vesicles. This change takes 
place by the formation on the top of each papule, of a little transparent 
elevation of the cuticle, beneath which is deposited a drop of serosit} 7 . 
The conversion of the papules into vesicles occurs first on the face, and 
then on the neck, trunk, and extremities. The vesicles are at first smaller 
than the papules, and acuminated in shape, but as they grow larger, be- 
come gradually flattened and depressed- in the centre ; after a time they 
cover the whole papule, and before long exceed it in size. As these 
changes take place, the fluid they contain loses its transparency, becomes 
opaline, and by degrees the vesicles are transformed into pustules, and 
thus the third stage of the eruption or that of suppuration begins. 

The pocks are more or less numerous, according to the extent and 
severity of the eruption. When scattered over the surface so as not to 
touch at their edges, the disease is said to be distinct or discrete ; when, 
on the contrary, so numerous as to come into contact and run together, 
it is called confluent. Of these two varieties, the latter is necessarily 
more severe and dangerous than the former, in consequence of the greater 
extent of tegumentary surface inflamed. During the various changes the 
vesicles undergo, they are surrounded by small, inflamed areolae, which 
differ in appearance according to the number of the vesicles. In cases 
of the discrete form, in which the eruption is sparse, so that the pocks 
are widely separated, the areolae fade gradually into the natural color of 
the skin, at the distance of a third or two-thirds of a line or more from 
the base of the vesicles, whilst in those in which the eruption is more 



SYMPTOMS OF THE ERUPTIVE STAGE. 749 

abundant, they run together, so that the spaces between the pocks are of 
a more or less bright red color. In confluent attacks, again, the areolae 
are more or less imperfect, according to the manner in which the vesicles 
are grouped together. 

The change of the vesicles into pustules takes place generally from the 
fourth to the sixth day of the eruption. During this process the fluid of 
the pocks becomes more and more opaque, whitish, and at length assumes 
a yellowish color, being in fact converted from serum into pus. At the 
same time the pocks become larger, begin to distend, and, as they ap- 
proach complete maturation, gradually lose their umbilicated shape and 
become convex on the surface. The formation of the pustules follows 
the same course as did the vesicles, beginning on the face and extending 
thence to the neck, trunk, and extremities. The areolae that have just 
been described as existing during the vesicular stage of the disease, con- 
tinue during the early part of the stage of pustulation, but decline to- 
wards its termination, assuming as thej^ disappear a purple tint. The 
number of pustules is in proportion of course to that of the vesicles, but 
from the increase in size of the pocks during the changes from papules 
into vesicles and pustules, the eruption, when at its height, seems to be 
greatly more extensive than would have seemed probable at the begin- 
ning of the first stage. As a general rule the pocks are most numerous 
on the face, and after that part on the neck and limbs. On the trunk 
the eruption is always much less abundant than on other parts of the 
body, and even when confluent in the highest degree on the face and neck, 
it is generally so only in patches on the limbs, while it is discrete on the 
thorax and abdomen. 

Simultaneously with the eruption upon the skin, there occurs one also 
upon the mucous membranes, particularly those of the mouth, nasal pas- 
sages, fauces, e3'elids, and sometimes of the prepuce and vulva. It begins 
with more or less vivid redness of the membrane, which is followed by 
the production of little elevations, the real nature of which, whether 
papular or vesicular, seems not to be clearly determined. About the 
second or third day these reel elevations assume the appearance of small, 
whitish, rounded, and umbilicated pseudo-membranous points, which last 
generally about five days, and are then detached, leaving usually a little 
ulceration or erosion, which heals without leaving a cicatrix. 

A short time after the appearance of the pustules in the mouth and 
throat, a true inflammation of the mucous membrane of those parts takes 
place. When the gums are inflamed they become swelled, red, and 
spong} r , and are clotted over with white pseudo-membranous points of a 
rounded shape. Sometimes the velum pendulum, and more rarely the 
tongue, present the same white points, with redness and injection of the 
membrane between. In most of the cases there is also partial or general 
inflammation of the pharynx, which occurs subsequently to the formation 
of the variolous pustules. The existence of this inflammation is denoted 
by more or less severe sore throat, attended with difficulty of swallowing, 
and with swelling and tenderness of the submaxillary glands. When the 
mucous eruption extends to the larynx, as often happens, there is pain in 



750 SMALL-POX. 

that part ; the voice becomes hoarse or whispering, and there is a hoarse,- 
laryngeal, smothered cough. The pharyn go-laryngitis just described 
occurs generally between the third and sixth days of the eruption, and 
ceases about the eighth or thirteenth. In some instances it does not 
exist at all or only to a slight extent. 

During the eruption there is more or less inflammation and swelling of 
the subcutaneous cellular tissue, the degree of which depends on the ex- 
tent of the eruption. The skin becomes tense, red, shining, and elastic 
under the finger, and more or less hot and painful. The swelling is 
greatest upon the face, where it commences about the fourth or fifth day 
of the eruption, and goes on increasing for five or six days, occasioning 
much pain, stiffness, and inconvenience to the child. The swelling di- 
minishes when desiccation begins, and ceases entirely as the latter is 
accomplished. 

It is important to stucty carefully the general symptoms of the second 
stage. The fever which existed during the initial stage sometimes con- 
tinues during the first day or two of the eruption. When, however, the 
papules are fulty thrown out, the fever subsides or disappears entirety, 
so that the pulse falls from 100, 120, or 140 beats, to 100, 80, 16, or 74, 
and the heat of skin diminishes at the same time. The child remains 
without fever usually throughout the vesicular period of the eruption, 
that is to say, until the fourth, fifth, or sixth day ; during which time the 
appetite sometimes returns, sleep is tranquil and quiet, and the patient 
is in most respects well and comfortable. 

About the fifth or sixth day of the eruption, at which time the matura- 
tion of the pustules is nearly completed on the face, and that process is 
commencing on the extremities, a new fever, to which the technical term 
secondary fever is applied, makes its appearance. The pulse rises again 
to 88, 100, 120, and 140, and becomes strong, hard, and full, whilst the 
skin is hot and dry. After continuing for some days the secondary fever 
diminishes after the suppuration is fully established, and disappears about 
the time that desiccation is nearly completed on the face, and has com- 
menced upon the limbs. It ceases generally, therefore, about the ninth 
or eleventh clay, having lasted between four and six days. This attack 
of fever is evidently the consequence of the suppurative stage of the dis- 
ease, or of the conversion of the vesicles into pustules. 

Towards the termination of the second stage, at the very height of the 
disease, when the pustules begin to break and discharge their contents, 
the patient exhales a peculiar, disagreeable, and fetid odor, which is char- 
acteristic of the disease. 

The third or declining stage is that of the desiccation or drying of the 
pustules and their desquamation. The desiccation commences generally 
between the sixth and ninth days, and terminates between the tenth and 
fourteenth. The formation of the crusts begins upon the face and ex- 
tends thence to the neck and limbs. It does not reach the limbs usually 
until about two or four days after it has commenced on the face. The 
mode in which the drying of the pustules takes place is not the same in 
all. In some a dark point is formed in the centre which gradually extends 



DESQUAMATION — DIGESTIVE SYMPTOMS — URINE. 751 

and converts the whole pustule into a hard crust ; in others the whole sur- 
face dries at the same time ; while in others again, the epidermis gives 
way and allows the contained fluid to escape, which then hardens into 
yellowish, irregular crusts, which become brown before they fall off. Some 
of the pustules, particularly those upon the arms and legs, do not form 
scabs at all, but shrink away from the absorption of their fluid, leaving 
behind nothing but pellicles of cuticle, which fall off by desquamation. 

The desquamation or falling of the crusts begins from the eleventh to 
the sixteenth, and ends somewhere between the nineteenth, twenty-fifth, 
and even fortieth cLoys of the eruption. When the scabs fall off the ap- 
pearances presented by the skin beneath vary in different cases. In some 
a true ulceration and loss of substance of the derm has taken place, 
which gives all the characters of a suppurating ulcer when desquamation 
has begun early in the disease ; when that process occurs at a later period, 
the ulcer is found to be dry and cicatrized. In both these forms of des- 
quamation, the cicatrices form little pits or depressions, which remain 
during life. In other instances the fall of the scabs leaves red and exco- 
riated surfaces which are on a level with the surrounding skin, but which 
soon dry, leaving blotches of a reddish-brown color, that do not disappear 
entirely for months. ]S T o cicatrices remain when desquamation takes 
place in this manner. In a third series of cases the crusts do not fall 
until the surface beneath has completely cicatrized, and the only traces 
left behind are more or less deeply tinted reddish spots, with occasional 
slight furfuraceous exfoliation of the cuticle, all of which disappear en- 
tirely after a time without leaving pits or cicatrices. 

To conclude the account of the symptoms of the disease, we have a few 
words to say in regard to the condition of some of the important organs 
throughout the course of the malady. 

The tongue presents no appearances peculiar to the disease, other than 
the eruption already described. It is generally moist, more or less furred, 
and either pale or red in color. The abdomen usually remains soft and 
undistended, though in some instances it is slightly tumid and hard, with 
occasional pains in the epigastric, umbilical, or iliac regions ; in simple 
cases, the latter symptoms rarely last more than a short time, and when 
otherwise they are almost always the sign of some complication. The 
constipation which exists during the initiatory stage generally continues 
throughout the disease, though in some instances a slight diarrhoea occurs 
about the end of the first or second week, after which the bowels regain 
their natural condition. If. severe diarrhoea should make its appearance, 
it is almost always the sign of a dangerous complication. The nausea 
and vomiting which are so often present during the initial stage, cease 
after the appearance of the eruption, and recur only in rare cases, or in 
consequence of some complication. The appetite is almost always lost 
during the course of the disease, though it sometimes returns in the period 
between the termination of the initial and the commencement of the sec- 
ondary fever; thirst is acute as a general rule, and more or less so accord- 
ing to the violence of the fever. 

The urine presents, during the course of the disease, the ordinary 



752 SMALL -POX. 

febrile characters of lessened quantity and heightened color. The urea, 
uric acid, and pigment are increased, and the chlorides much diminished. 
Albuminuria is occasionally present at the height of the disease ; it is, 
however, temporary, and apparently not of very grave import. Casts of 
the renal tubules are also present in some cases. The frequency with 
which this condition exists probably varies in different epidemics, since 
we detected it in but one of our cases, while Parkes states that it is present 
in about 30 per cent, of all cases. In the hemorrhagic form, the urine 
often contains blood corpuscles, or is deeply stained with dissolved hsema- 
tine. After the subsidence of the secondary fever, the urine frequently 
becomes very abundant, of pale color, and of low sp. gr. Thus, in one of 
our cases, in a girl aged 18 years, the daily amount of urine passed from 
the tenth to the thirteenth day of the eruption was f ^clx, or ten pints, of 
sp. gr. 1001, as clear as spring-water, containing no albumen, but with a 
fair proportion of chlorides. In another case, in a young man aged 20 
3'ears, the patient also passed, on the eighteenth day, f^clx of crystal- 
clear urine, of sp. gr. 1007, without albumen, but containing abundant 
chlorides. In a third case, in a boy aged 13 years, the amount, on the 
twelfth day of the eruption, was f^xlv. 

The strength of the child is not, as a general rule, greatly diminished, 
except in severe and dangerous cases. Restlessness, irritability, crying, 
and delirium, which are of such frequent occurrence in the febrile dis- 
eases of children, are not usually very strongly marked in regular cases 
of variola. They exist, but it is to a moderate extent only. In severe, 
irregular, and confluent cases, on the contrarj^, restlessness, crying, and 
delirium, are present in a veiy high degree, either towards the termina- 
tion of the attack, or throughout its course, and they are then of very 
bad augury. 

We shall here conclude the history of the symptoms of the regular 
form of the disease. We have not given a separate account of the dis- 
crete and confluent cases, as they are merely different degrees of the same 
affection ; the latter being much more severe and dangerous, from their 
greater intensity, than the former. We will remark merely that all the 
symptoms are very severe in confluent cases, particularly the fever and 
those which indicate disorder of the nervous system. 

We shall proceed next to a description of some of the irregularities of 
the disease, or, as expressed by some writers, of irregular or abnormal 
variola. We would remark, in the first place, that a large number of the 
cases that have been called confluent, ought rather to be called irregular, 
since man}^ of the symptoms detailed as belonging to that form of the 
affection, depend, not upon the confluent nature of the eruption, but upon 
the existence of some irregularities in its characters, entirety indepen- 
dent of the confluence or running together of the pustules. 

The first or initial stage of irregular variola may be either longer or 
shorter than in the regular form. As a general rule, the symptoms of this 
stage resemble very closely those of the regular form, when the attack 
occurs in a child previously in good health ; whilst in secondary attacks 
they present differences which are more or less strongly marked. The 



SYMPTOMS OF THE IRREGULAR FORM. 753 

most important of these are the greater infrequeney of headache, vomiting, 
and of the lumbar pains ; the presence of diarrhoea rather than constipa- 
tion; the greater frequenc} r of sleeplessness, oppression, and restless- 
ness ; and. as a general rule, the earlier appearance of the eruption. 

The second or eruptive stage generally passes through its periods with 
much greater rapidity, so that the conversion of the papules into vesicles 
occurs as early as the first or second day, and that of the vesicles into 
pustules, between the second and fourth days. In some few cases, on the 
contrary, the eruption is retarded, and the papules may remain unchanged 
as late even as the fifth or sixth clay. The progress of the eruption is so 
irregular sometimes that there may exist upon the same surface, papules, 
vesicles, pustules, and scabs. 

The appearances presented by the eruption often differ widely from 
those which have been described as characteristic of the regular disease. 
The papules ma}^ be pale, irregular, uneven, and destitute of areolae ; and 
when this happens, the vesicles and pustules which follow usually present 
the same peculiarities. In other instances the papules and areolae are of 
a purple-red color, and the vesicles, instead of being transparent or 
whitish, are also reddish, and appear to be filled with a bloody serum. 
The pustules in these cases also contain a sanguinolent fluid, and when 
broken, their contents escape and form bloody scabs. In this variety of 
the disease, which is called hemorrhagic, the papules and vesicles are 
very small ; they are developed slowly, and remain flat and undistended, 
as a general rule, whilst in a few cases they are of a larger size, but re- 
main almost always flattened in shape and unfilled. The scabs, when they 
form, are thin, soft, easily detached, and leave beneath bleeding surfaces 
and scarred pits. This form of the eruption, indicating, as it does, a pro- 
found alteration of the crasis of the blood, with a tendency to passive 
hemorrhages from every surface, is associated with the gravest typhoid 
state of the system, and is indicative of the greatest possible danger 
to life. 

The fever of the initial stage rarely subsides in irregular variola, upon 
the appearance of the eruption, as it does in the regular disease; but, on 
the contrary, usually goes on augmenting. The distinction, therefore,, 
into primary and secondary fever does not properly exist. Sometimes,. 
however, a notable increase of fever does take place at the period when 
the vesicular passes into the pustular stage of the eruption. The fever 
is usually more violent in the form of the disease under consideration, 
than in regular attacks, the pulse being full and large, and rising as high 
as 160. In fatal cases it becomes small towards the termination. The 
skin is generally very hot and dry. 

The appearance of the tongue, condition of the abdomen, appetite, 
thirst, and nervous s} r mptoms, are of the same character as in the regu- 
lar form, except that the signs which they present are more severe and 
unfavorable, particularly the delirium, agitation, and cries. 

Varioloid, or Modified Small-pox. — This is a term now usually ap- 
plied to the modified form of the disease, as it occurs in individuals who 

48 



754 SMALL -POX. 

have beeu vaccinated, or who have already bad the natural or inoculated 
disease. 

The symptoms of this form of variola are, in general, the same as those 
of the regular disease, the only difference being in their greater mildness 
and shorter duration. The attack usually begins with slight fever, head- 
ache, languor, and sometimes constipation, which are followed in two or 
three days, by the eruption. The vomiting, lumbar pains, and different 
nervous symptoms which exist in regular variola, are not often present, 
or, if so, in a very slight degree. The eruption consists of papules like 
those of true small-pox, but usually they are few in number, and entirely 
discrete in their arrangement. The initial fever and other symptoms sub- 
side completely upon the appearance of the eruption, and the child often 
seems perfectly well. 

The progress and character of the eruption are very similar to those of 
the regular form of the disease, with the exception that the changes are 
more rapidly effected, and, as a consequence, the duration of the attack 
is rendered by so much the shorter. The papules are converted into 
vesicles at a much earlier period — as earfy as the first or second da}'. 
The vesicles soon assume a whitish, opaline appearance, become umbili- 
cated, and in the course of the second or third day begin to change into 
pustules. The suppurative stage of the eruption, or maturation, is seldom 
accompanied by the same marked secondary fever as in the regular dis- 
ease. When the fever does occur, it is generally very moderate, consist- 
ing merely in slight acceleration of the pulse and a little increased heat 
of skin, and in one or two days it disappears entirely. The pustules do 
not fill usually so well as in regular variola, and not unfrequently their 
contents are rather sero-purulent, than purulent, in the proper sense of 
the term. The third stage occurs earlier and goes through its periods 
more rapidly than in true small-pox; desiccation soon takes place, is 
speedily finished, and the falling of the scabs, which begins as earl}' as 
the eighth day of the eruption, is usually completed about the twelfth or 
fourteenth. After desquamation is completed, the only traces of the dis- 
ease left are reddish spots or blotches, which disappear after a time with- 
out leaving cicatrices. The whole duration of the attack is generally 
from ten to twent} T days. 

Complications. — The most frequent and important complications of 
variola in children, are inflammations of the mucous membrane of the 
lower half of the intestinal tube, ophthalmia, otitis, and different hemor- 
rhages. In a smaller number of cases, attacks of bronchitis, pneumonia, 
anasarca, articular inflammations, subcutaneous abscesses, simple and 
pseudo-membranous coryza, angina, and laryngitis, and other eruptive 
diseases, occur at different periods of the malady. 

It is impossible for us, for want of space, to attempt a description of 
the various symptoms of the different complications just enumerated. 
Having mentioned the possibility and probability^ of their occurrence, we 
must leave the reader with the advice always to suspect the existence or 
approach of some one of them, when the symptoms, in any case, differ 



ANATOMICAL LESIONS. 755 

much from those which have been described as characteristic of the regu- 
lar form. 

Anatomical Lesions. — The characteristic lesions of small-pox are a 
certain deteriorated state of the blood, congestion of the internal organs, 
and the inflammation of the skin and mucous membrane constituting the 
eruption. The blood is found to -be entirely liquid and uncoagulable, and 
of a dark color ; or if coagula exist, they are small, soft, and very dark in 
color. The exceptions to this rule are those in which some acute and 
severe inflammation exists, under which circumstances the dissolved state 
of the blood is less marked, and fully-formed coagula are more abundant. 
The congestion referred to affects almost the whole sj'stem. The muscles 
are firm and of a deep red color ; the membranes of the brain are strongly 
injected, the sinuses are filled with blood, and the cerebral substance pre- 
sents numerous red points or dots. The vessels of the lungs contain a 
large quantity of blood, and the liver, spleen, and kidneys, are all deeply 
congested. 

The condition of the mucous membranes is important. The pharynx, 
larynx, and trachea, present an eruption, or simple inflammation without 
eruption. The eruption exists under the aspect of small, circular, thin, 
and whitish pseudo-membranous points, scattered over the mucous tissue, 
and slightly adherent to it, beneath which that tissue is often observed 
to be red and inflamed. At a more advanced degree, and in severer cases, 
the false membranes have disappeared, and in their places we find circu- 
lar ulcerations, which are either superficial, or the}^ penetrate the tissue 
of the mucous coat and rest upon the muscular, or even pierce that and 
reach to the cartilaginous tissue beneath. In addition to these lesions 
are found inflammation of the mucous tissue with its consequences, red- 
ness, softening, thickening, and extensive deposits of false membrane, 
quite distinct from the appearances above described as characteristic of 
the eruption upon these tissues. 

It has been a contested point whether a true vesicular or pustular erup- 
tion ever exists upon the mucous lining of the stomach and intestines. 
The general opinion appears now to be, however, that the changes ob- 
served in these organs cannot be ascribed to the formation either of vesi- 
cles or pustules. The appearances that have led some observers to con- 
sider them as the result of a proper eruption, are the following. The fol- 
licles at the commencement and termination of the small intestines, and 
in rarer cases, of the large intestine also, present an abnormal degree of 
development, appearing in the form of small hemispherical or pointed, and 
sometimes flattened projections, on which there often exists a dark, and 
sometimes depressed central point. At the same time the plaques of 
Pej^er are often enlarged, more projecting than usual, softened, and red. 

The anatomy of the variolous pock is important and interesting. When 
a vesicle is opened soon after its formation, it is found to contain nothing 
but a little serosit}^ which is perfectly limpid and alkaline, while the skin 
beneath is red, softened, and moist. The umbilicated character depends 
on a filiform adhesion between the centre of the pock and the surface of 
the skin beneath. This adhesion is broken, when, at a later period, the 



756 SMALL-POX. 

pustule becomes globose in shape. The vesicle is also subdivided into 
several chambers by delicate radiating partitions, so that a single punc- 
ture will not discharge the entire contents. About the period of the con- 
version of the vesicles into pustules, or very soon after the formation of 
the latter, the cavity of the pock will be found to contain a false mem- 
brane, which is of au opaque white color, soft and friable in its texture, 
and seated upon the derm in small isolated points. After a time these 
points enlarge, and meeting, unite, and form a soft pseudo-membranous 
disk, uneven upon its surface, and which either fills the pock completely, 
or is covered at first with serosity and afterwards with pus. This false 
membrane is secreted originally by the true skin. At a somewhat later 
period it forms an adhesion to the inner surface of the cuticle, while still 
later in the progress of the pock, it become detached from the cuticle, 
and remains loose and free in the cavity of the pustule, surrounded by 
the fluid contents of the latter. 

Diagnosis. — The most important point in the diagnosis of variola is its 
recognition during the prodromic or initial stage. The only symptoms 
that can be depended upon as indicating with any considerable proba- 
bility the approach of the disease, are the simultaneous existence of fever, 
constipation, bilious vomiting, and severe pain in the back, in a child not 
previously vaccinated, and in whom there is no more probable mode of 
accounting for the s3 r mptoms enumerated. If, in addition to these cir- 
cumstances, the disease be extensively prevalent at the time, and still 
more, if the child has been exposed to the contagion of the maladj-, the 
diagnosis becomes almost certain. After the eruption makes its appear- 
ance the diagnosis is seldom doubtful. There may be some doubt for the 
first few hours, but the hard, shotty character of the papules, their rapid 
enlargement, the subsidence of the fever, and then the change into vesi- 
cles, remove all uncertainty as to its real nature. 

Prognosis. — The fatality of variola varies greatly in different epidemics. 
The result is also markedly influenced by the age of the patients ; thus all 
of the 5 fatal cases that we met with, in a series of 23, occurred under the 
age of five years, and 3 of them during the first year of life. 

The prognosis of variola must also depend very much upon the form 
which it assumes. The regular form of the disease generally terminates 
favorably unless some complication happens to occur, in which case the 
danger to life is greatly augmented. When the eruption is discrete, the 
attack is usually more mild, and the result more favorable, than in the 
confluent form ; though nearly all cases of simple uncomplicated regular 
variola, occurring after the first infanc}', recover, whether discrete or con- 
fluent. Irregular variola, on the contrary, is fatal in a large proportion 
of the cases. MM. Rilliet and Barthez state that only 3 recovered out of 
39 that came under their observation. The hemorrhagic form of the dis- 
ease is, also, almost without exception, fatal. 

The varioloid disease is very rarely fatal. 

The favorable symptoms in any case of variola are the occurrence of 
the disease in children previously in good health ; the absence of any 
violent nervous symptoms during the initial stage ; a proper duration of 



TKEATMENT. 757 

the first stage ; and subsidence of. the fever after the appearance of the 
eruption. When, in addition to these circumstances, the secondary fever 
is not too violent, and no complication arises, there is but little doubt 
that the patient will recover. 

The unfavorable symptoms are the occurrence of the disease at a very 
early age; the existence of severe nervous symptoms during the first 
stage ; the occurrence of a thick and abundant eruption upon the face, 
indicating a probably confluent case ; continuation of the fever after the 
appearance of the eruption, or a merely slight subsidence of it; delirium 
and other nervous s} T mptoms during the secondary fever ; and any irregu- 
larity in the appearance of the eruption, as paleness instead of the usual 
red color, a livid or purplish color of the pustules, imperfect development 
of the pocks, or their sudden shrinking without diminution of the general 
sjmiptoms. It is scarcely necessai\y to say that many of these symptoms 
are indicative of the existence or threatened production of some compli- 
cation, upon the nature of which must depend, after all, in great measure 
our prognosis. The complications most apt to occur have already been 
considered in a previous article. 

Treatment. — We shall begin our remarks upon the treatment of the 
disease with the following quotation from Dr. Gregory ( Tweedie?s Lib. of 
Prac. Med., Am. ed., vol. i, p. 332). " Before entering on the curative 
treatment of small-pox, therefore, it will be proper to recall to* remem- 
brance the peculiar nature of the disorder. It is a fever which relieves 
itself by superficial eruption. That eruption, even when too copious, 
cannot be diminished or checked in its progress by any effort of art ; 

when moderate it requires not the interference of the physician." 

" Heroic remedies are here wholly inapplicable, and the great object of 
art is simply to place the system under the most favorable circumstances 
for effecting what the old physicians called the concoction and elimina- 
tion of the morbid humors." 

The treatment of simple, uncomplicated small-pox ought, unless the 
attack be confluent, to be of the mildest character. Rest in bed, light 
diet, cooling drinks, some gentle laxative, and an occasional foot-bath 
during the first stage, are all that is required in most cases. When, how- 
ever, the fever is considerable, and the child restless and complaining, 
we may add to these means a diaphoretic, as the saline or effervescing 
mixture, with small doses of sweet spirit of nitre, or spiritus Mindereri ; 
or we may direct from one to three drops of the antiinonial wine, with ten 
or twenty of sweet nitre, for a child of four years old, every two hours. 
Should this produce much vomiting, or any action upon the bowels, it 
must be suspended. If the fever be violent, either during the initial 
stage, or later in the attack, with a full strong pulse, great heat and 
swelling of the skin, severe headache, or signs of congestion of the in- 
ternal organs, we should recommend the use of cold applications to the 
head, conjoined with hot mustard foot-baths. It may also be necessary, 
to relieve the violent pain in the back of the neck, or in the lumbar region, 
to apply either a few cups or a sinapism to these parts. 

Laxatives should be administered so as merely to secure a complete 



758 SMALL -POX. 

evacuation of the bowels, and subsequently to keep them in a soluble 
state ; but all active purgation should be carefully avoided. 

Even under the circumstances above supposed, where the febrile symp- 
toms are so violent, general bleeding should never be emplo3 T ed, and 
even local depletion, as by leeches or cups to the back of the neck, is un- 
necessary, since as much relief is obtained by dry cupping and the use of 
cold applications to the head. It must also be remembered that the severe 
S3 T mptoms of the initial stage disappear promptly on the appearance of 
the eruption. 

When the eruption comes out slowly and tardily, remaining for an un- 
usual length of time in the papular state, or forming small and flattened 
vesicles, the pulse being at the same time frequent and undeveloped, we 
may hasten its appearance by the use of a warm diaphoretic infusion, as 
balm or sweet-marjoram tea, with spiritus Mindereri, by putting additional 
covering upon the child, and by the employment of warm baths, of mus- 
tard foot-baths, and of mustard poultices to the epigastrium. 

In severe cases, attended with copious eruption, the diet should be 
highlv nourishing, though readily digestible; and at the same time, in 
addition to the use of cooling drinks and febrifuges as already recom- 
mended, the strength should be supported b}' tonics, and the early use 
of stimulants. We would especially recommend the use of quinia, which 
may be given in full tonic doses with advantage, throughout the entire 
course of these severe cases. 

The nervous symptoms which attend the secondaiy fever, require the use 
of nervous and diffusible stimuli, conjoined with opium in doses sufficient 
to secure quiet sleep. When the period of secondaiy fever is accompanied 
with s3 T mptoms of extreme debility, as feeble pulse, brownish tongue, cold- 
ness of the skin, typhoid expression of the countenance, subsultus tendi- 
num, and general tremors, the treatment must consist in the use of nutri- 
tious diet, and of stimulants, as wine and brandy, carbonate of ammonia, 
and quinia or compound infusion of cinchona. Camphor, administered in 
doses sufficient to allay the disturbance of the nervous S3 7 stem, is an excel- 
lent adjuvant to the stimulants just mentioned. In cases of hemorrhagic 
variola the above stimulating treatment must be made use of, in connec- 
tion with the use of bark or quinia in large doses, and of some of the 
mineral acids, and tincture of the chloride of iron. The quinia ought to be 
given in closes of a grain every hour or two, so that from six to ten grains 
ma3 r be taken every da3^. 

Treatment of the Complications. — It maybe stated in general terms, 
that the treatment for the different complications must be controlled by 
the fact that they occur under the influence of the general blood disorder. 
Thus, acute inflammation must be treated with great care and reserve, in 
consideration of the length of time during which the patient must be sick, 
and the necessity there is for preserving his strength and maintaining a 
proper crasis of the blood, in order that he may be enabled to carry on the 
various changes in the disease requisite to effect a return to health. These 
remarks apply particularly to angina, laryngitis, bronchitis, pneumonia, 
and entero-colitis. When the acute affection is only of moderate extent 



TREATMENT OF COMPLICATIONS. 759 

and severity, it is best, except in the case of intestinal inflammations, to 
depend upon a moderate employment of laxatives, of small doses of sul- 
phurated antimony, or of one of the alkalies, in conjunction with diapho- 
retics, and of gentle counter-irritants. 

We must also bear in mind that the increased depression caused by the 
superadded local affection, usually requires the employment ultimately of 
still more supporting and stimulant remedies, than are called for in un- 
complicated cases. 

The treatment of the ophthalmia which so often threatens, and some- 
times occasions great or irreparable injury to the eye, must be of the kind 
just recommended. In this complication the local treatment is exceed- 
ingly important. When ulcerations occur upon the cornea, they ought 
to be touched, if this be practicable, with solid nitrate of silver, sharp- 
ened to a point, or with a fine camel's-hair pencil which has been moistened 
and rubbed over the nitrate of silver crystal to insure a caustic solution. 
When it is impossible to apply the solid caustic or the brush, we must 
resort to some collyrium. This may consist of a solution of nitrate of 
silver, a grain to the ounce, or of one or two grains of sulphate of zinc, 
with twenty or thirt} 7 drops of wine of opium, dissolved in an ounce 
of rose-water, two or three drops of either of which are to be introduced 
into the eye morning and evening. When the first solution is used, its 
strength should be increased after a few days to a grain and a half or two 
grains, or even more, to the ounce of water. 

The complication of entero-colitis must be treated by the most careful 
attention to diet, the use of warm poultices to the abdomen, of emollient 
and anod^me injections, and by the internal administration of astringents 
and small doses of opiates. When the diarrhoea is severe, and the stools 
mucous or blood} T , we may use with advantage the nitrate of silver in- 
ternally or b}^ enema, in the manner directed in the article upon entero- 
colitis. 

The treatment of the convalescence from variola is important. The 
same rules apply to it as to other infantile and children's diseases. 

Before terminating our remarks upon the subject of small-pox, it will 
be proper to give some account of the treatment of the eruption which 
has been recommended and practised, with a view to prevent the scarring 
and disfiguration which so often result from the ravages of the disease. 
Of the different means that have been employed with this view, there are 
two which are almost exclusively relied upon at present. One is to cau- 
terize the pustules with nitrate of silver, and the other to make a mer- 
curial application upon the part where it is desirable to cause the abor- 
tion of the eruption. The cauterization has been performed in two 
modes ; by the application of the caustic to each pustule separately, or to 
masses of the eruption without puncturing the cuticle. It appears, how- 
ever, that the first-named method is much the most preferable. To succeed 
perfectly, it is necessary to touch the derm forming the base of the pus- 
tule ; so that the best plan is to remove or lift up a portion of the top of 
the vesicle with a lancet, and then to introduce into its interior the sharp- 
ened point of a stick of caustic. This operation is only certainly success- 



760 SMALL-POX. 

fill when performed on the first or second day of the eruption, though 
MM. Rilliet and Barthez have known it to answer as late as the third and 
fourth, or even fifth da}^. The process of cauterization is productive of 
acute pain, but does not increase the local inflammation, according to the 
authors just quoted, at least when applied to a small number of the pocks. 
They state that when applied to the pustules seated upon the edges of 
the eyelids, it is almost incredible to behold how great is the diminution 
of the oedema of those parts in a single clay. The conclusion of these 
gentlemen is, that individual cauterization of the pustules with nitrate of 
silver does certainly cause them, as well as the surrounding tumefaction, 
to abort, and prevents them from leaving cicatrices. 

This plan is, however, manifestly inapplicable to any but cases of the 
discrete form, where the vesicles are not veiy numerous. 

The other method which has been emphryecl to cause the abortion of 
the pustules and thus prevent disfiguration is, as has been stated, the 
application of some one of the mercurial preparations. The effects of 
this treatment are said to be an almost certain arrest of the development 
of the eruption, when it is used from the first or second, or not after the 
third day ; the vesicles and pustules remaining small and isolated, and 
not assuming, or else soon losing, the umbilicated character. When 
applied early, while there are as yet but few vesicles formed, it prevents 
the development of new T ones, and diminishes the accompanying swelling 
and soreness. When the application is removed on the seventh or eighth 
day, it is found that desiccation has occurred imperfectly, the surface 
presenting small soft scabs, or little whitish, soft elevations, consisting 
of the pseudo-membranous substance situated between the true skin and 
the new epidermis, the old cuticle having generally peeled off with the 
plaster. In some places a light rose-colored surface alone remains. 

In regard to the success of this treatment in preventing disfiguration, 
we may quote the statement of MM. Rilliet and Barthez, that none of the 
patients upon whom the\r saw it tried presented any cicatrices, though 
several had had confluent small-pox, which pursued its usual course on 
the parts not covered b}^ the application. Dr. Stewardson, of this city, 
made a considerable number of trials of this treatment at the Small-pox 
Hospital of this city in 1841-42. He gave his conclusions in the follow- 
ing words (Am. Jour. Med. Sci., January, 1843, p. 86-7): "From these 
experiments, it seems pretty evident that the mercurial plaster has a de- 
cided influence upon the small-pox pustules, preventing more or less com- 
plete^ their perfect maturation, and diminishing the concomitant swell- 
ing and soreness, the process of desiccation being completed without the 
formation of thick scabs, and the resulting cicatrices less marked than 
when the process of suppuration was left to pursue its natural course." 

" That by its use pitting may be entirely prevented, or the 

mortality from small-pox materially lessened, seems to me very doubtful, 
although had all the precautions above-mentioned been taken, it is not 
improbable that the effects would have been still more decided." 

The use of the mercurial application is attended with some inconveni- 
ence. In the first place it is difficult to keep it accurately applied, par- 



APPLICATIONS TO PREVENT PITTING. 761 

tieularly in children, in consequence of the unpleasant sensations it occa- 
sions. In the second place, it not very unfrequently, according to MM. 
"Rilliet and Barthez, produces an eruption of hydrargyriasis or mercurial 
roseola, in about eight or fourteen days after the variolous eruption, or 
four or ten after the application of the remedy. M. Rayer, however, 
states this effect to be a rare one. 

Dr. Stewardson sa} T s that he thinks no apprehension need be felt as to 
constitutional affection from the mercury, for scarcely ever were the gums 
even touched. One of ourselves, however, when in Paris, in 1840, saw 
this effect produced in a .young girl at the Children's Hospital. 

The method of its application is different in different hands. The 
French generally emplo} T the emplastrum de Yigo cum mercurio. Dr. 
Stewardson prefers the strong mercurial ointment, either pure or rubbed 
down with an equal bulk of lard, spread upon a piece of thick muslin. 
The muslin is to be cut into the shape of a mask, with apertures for the 
eyes, nose, and mouth. It is secured upon the face by means of strings 
attached to its margin and tied across the back of the head and neck. It 
is important alwa3*s for the success of the measure, that the application 
should be kept in close contact with the skin. To insure this, Dr. S. 
employed a separate piece of muslin for the nose, which is the part most 
difficult to fit. With the same view, the French authors recommend that 
the plaster should be cut in pieces to suit the different portions of the 
face, making one for the forehead, and others for the cheeks, sides and 
back of the nose, and upper and lower lips. Any spaces that may remain 
are to be covered with other portions of the plaster, and the whole se- 
cured with strips of diaclrylon. On account of the difficulty of applying 
the mercurial plaster, the following ointment was compounded by the 
apothecary of the Children's Hospital at Paris, and has been found to 
answer very well: 

R. — Mercurial Ointment, . , . .24 parts. 

Yellow Wax, 10 parts. 

Black Pitch, 6 parts. — Mix, 

The application ought to be confined to the face, as that is the part 
which it is most important to save from disfiguration, and as it is better 
not to use it upon a larger surface than necessary, lest it might occasion 
the mercurial roseola, or possibly salivation. As a general rule, four or 
five da} T s are sufficient, according to Guersant and Blache, to leave it in 
contact with the skin, in order to avoid the bad effects just referred to. 

The object sought in these applications being, to a great extent, to 
protect the vesicles from contact with the atmosphere, it has been advised 
to paint a saturated solution of gutta percha in chloroform, over the neck 
and face, so soon as the papular eruption is fully out. This plan was 
tried in five of our own cases (loc. cit., p. 345), two of which were dis- 
crete, and three confluent, and with very satisfactory results. 



762 VACCINE DISEASE. 



ARTICLE IV. 

VACCINE DISEASE. 

Definition ; Synonymes ; History. — The vaccine disease is an affec- 
tion produced by the inoculation of the virus of variola, modified by 
passing through the S3-stem of the cow. 

The proofs which exist as to the truly variolous nature of the vaccine 
disease in the cow, are altogether incontestable ; so that we must regard 
the vaccine disease in the human subject merely as a remarkably modi- 
fied form of variola. 

It is susceptible of propagation from individual to individual by inocu- 
lation, but is contagious in no other way, and it possesses the invaluable 
quality of protecting, with very great, though not with absolute certainty, 
those through whom it has passed, against small-pox. 

Besides the name given above, it is known by the titles of cow-pox, 
kine-pock, vaccina, and vaccinia. 

Some knowledge of the nature of the vaccine disease, and of the power 
it possesses to protect the human constitution against small-pox, has been 
found to have existed in different parts of the world, but there can be no 
doubt that it is to the genius and patient research of Dr. Jenner that we 
owe the inestimable blessing of vaccination, since it was by him that its 
marvellous virtue was first demonstrated and proclaimed to the world. 
Dr. Jenner learned, at an early period of his life, that there existed a 
popular belief in Gloucestershire, in England, that persons who had con- 
tracted a peculiar vesicular disease from the udder of the cow, were 
thereby protected from the attack of small-pox. Becoming convinced by 
a long course of patient observation, that this belief was founded in fact, 
he determined at last to try whether the disease might not be transmitted 
from one person to another, and thus increase immeasurably the utility 
of this wonderful protective means. On the 14th of May, 1796, accord- 
ingly, he vaccinated a child eight 3 r ears old with matter taken from the 
hands of a milker who had received the disease from the cow. The ex- 
periment succeeded perfectly, the child having received and passed 
through the disorder in the most satisfactory manner. On the 1st of 
July following this child was inoculated with variolous matter, and re- 
sisted the contagion entirely, as Dr. Jenner had expected. It was not, 
however, until two years later, in It 98, after additional experiments, that 
the results of his researches were published to the world. Erom this time 
the belief in the utility of vaccination and its application in practice 
spread rapidly throughout England. In 1*799 it was introduced into this 
country ; in 1800 it reached France, and in the course of a very few years 
extended to all civilized nations. 

Symptoms ; Course. — It is very important for the physician to be 
thoroughly acquainted with the appearances presented by the vaccine 
disease in its various stages, since he is to judge by those appearances 
whether the subject has had the disease in such perfection as to derive 



SYMPTOMS. 763 

all the benefit from its protective power which it is possible for it to 
impart. 

The first effect of the puncture by which the virus is introduced into 
the tissues, is to produce a very slight redness at the point where the 
operation is performed. This redness usually disappears within twenty- 
four hours, and there is left merely a little mark or scab at the point of 
insertion. On the third day after the operation we first begin to perceive 
the specific effects of the virus, in the shape of a small, hardened point at 
the seat of the wound, surrounded b} T a faint, erythematous redness. Over 
this hardened point, which grows gradually larger, the cuticle is elevated 
on the fifth day into a vesicle, by a thin, transparent, and pearl-colored 
serous exudation. This vesicle soon becomes umbilicated, so that by the 
following day, the sixth, the depression in the centre, constituting the 
umbilicated character, is generally perfectly manifest, and at the same 
time the vesicle is surrounded by a very narrow ring of inflammation. 
The vesicle continues to increase in size, until on the eighth or ninth day 
it has reached its highest degree of development. At this stage the ves- 
icle or pock is large, usually about one-third of an inch in diameter, and 
it projects very considerably above the general surface. Its shape is cir- 
cular, as a general rule, though not unfrequently it is oval, this depend- 
ing apparently upon the mode in which the puncture has been made. 
The color of the pock is dull white or pearly, or sometimes it has a yel- 
lowish tint. The quantity of fluid contained in the cavity of the vesicle 
differs, of course, according to its size. The structure of the pock is 
found, upon careful examination at this time, to be cellular, the number 
of cells amounting commonly to eight or ten ; very often there is a small, 
dark-colored scab on the very centre of the vesicle, even at this period, 
though in other instances this is absent, the surface of the vesicle being 
formed exclusively of the thin and transparent cuticle. The scab just 
alluded to has seemed to us to consist of the little incrustation, formed 
at the point where we had introduced the virus by the drying up of the 
minute quantity of blood escaping after the puncture, and of the dissolved 
virus which had not been absorbed. We have often noticed that when 
the small scab just alluded to has been rubbed off the arm on the second 
day, the vesicle has presented no scab as early as the eighth day. On the 
eighth day the little ring of redness at the base of the pock, which has 
hitherto been very small and narrow, begins to enlarge so as to form the 
areola. This increases during the ninth and tenth days, forming a bril- 
liant scarlet or dark-red inflammatory circle of about two inches in diam- 
eter, and constituting one of the most strongly-marked features of the 
vaccine disease. The color of the ring is most intense at the edge of the 
vesicle, and then fades gradually to its outermost boundary. On the ninth 
and tenth days, in connection with the areola, the skin and cellular tissue 
on which the vesicle is seated, and that for a short distance beyond the 
margin of the latter, become hardened and tumefied, forming a solid knot 
or lump in the derm, like the base of a furunculus. The inflammation 
which causes the areola is often so intense as to occasion the production 
of vesicles, which are almost always discoverable with the aid of a lens. 



764 VACCINE DISEASE. 

and are sometimes distinctly visible to the naked eye. On the tenth da}' 
the disease is usually at its height, and it is then of course that all its 
peculiar characteristics are most strongly marked. At this time the 
child, when of an age to describe its sensations, will often complain of 
heat, itching, and pain in the inflamed spot ; the arm is heavy and not 
willingly moved, or it is moved with care and caution ; there is, in a good 
many instances, some irritation and swelling of the axillary glands, and 
very frequently a decided febrile reaction ma}- be noticed. In other 
cases, on the contrary, none of these symptoms will be present. .The 
child is gay and cheerful, its movements free, quick, and unembarrassed, 
and it seems in all respects to be in its ordinary condition of health. 

From the tenth clay the disease begins to subside. The areola fades 
so as to have nearly disappeared by the fourteenth day ; the fluid con- 
tained in the vesicle is gradually converted into pus, and the cellular 
structure of the pock is broken down so as to form, by the thirteenth day, 
but a single cavity, in which the pus is contained ; the process of desic- 
cation is going on rapidly during this time, so that about the fourteenth 
day the vesicle has disappeared, and in its place there is a firm, hard 
scab, of the shape and size of the vesicle. This scab continues to harden 
for some days longer, and at the same time contracts somewhat in size 
and grows darker in color, until at last it is of a very dark brown or 
mahogany tint. It separates gradually from the tissues beneath, the 
separation beginning at the circumference, and falls off usually about the 
eighteenth or twenty-first day, leaving beneath a small ulcer, which soon 
heals, or else a cicatrix of the shape and size of the pock. The cicatrix 
is at first of a deep red or purple color, but fades gradually, until it be- 
comes much whiter than the surrounding skin. The scar left by the 
vaccine disease is very characteristic, and is often, though not by any 
means invariably, indelible. To be at all depended on as a mark of the 
disease, the scar should be small, circular, of a smooth and somewhat 
shining appearance, and it should exhibit radiations and little depres- 
sions or pits. The depressions are supposed to have been caused by the 
cells constituting the pock in its early period. 

There is rarely more than a very slight constitutional disturbance 
attendant upon the course of this disease. About the eighth day, a de- 
cided febrile reaction, attended with some unusual warmth of the surface, 
restlessness at night, and fretfulness of the temper, is often observed. In 
a few instances we have noticed distinct disturbance of the health about 
the third and fourth days ; amounting only, however, to unusual irrita- 
bility and discomfort through the day, and to wakefulness or disturbed 
sleep at night. 

Irregularities and Anomalies. — We have now described the regular 
course of a vaccination — that which it pursues in a large majority of the 
cases. Certain variations from the above standard or typical course are 
frequently, however, met with, and require some notice. These varia- 
tions may consist merely in the degree of severity of the local and general 
symptoms, or in the appearances presented by the pock, without affecting 
at all the validity of the disease ; or they may concern the duration of 



IRREGULARITIES. 765 

the phenomena ; or, lastly, they may be such as to call in question the 
validity of the disease, leaving us in some doubt as to whether it has pro- 
tee-ted the constitution against variolous attacks or not. 

The severity of the local inflammation occasioned by the vaccination, 
and that of the general sj T mptoms also, varies often to a considerable ex- 
tent. In some instances, and especially when the virus employed has 
been procured recently from the cow, the specific inflammation proves 
very severe. We have seen the arm intensely red, and very considerably 
swelled, from the shoulder to an inch below the elbow, while at the same 
time the axillary glands were tumefied and tender, and the child very 
feverish and uncomfortable. This happened in three children, in all of 
whom we had emplo}'ed the same virus ; which, as we afterwards learned 
of the person from whom we obtained it, had been taken quite recently 
from the cow. It produced the same violent inflammation, moreover, in 
several other subjects in whom it was employed. 

If the vesicle happens to be broken by accident soon after its forma- 
tion, its appearances during the subsequent progress of the disorder will 
often be very different from those exhibited in subjects in whom no such 
accident occurs. The vesicle loses a portion of its contents ; it becomes 
conoidal and irregular in shape, instead of being circular and umbilicated ; 
it does not exhibit the pearly white and diaphanous color which belongs 
to it, but is yellowish and opaque; the areola is often premature and 
irregular in shape, and the scab is frequently small, uneven on the edges, 
and falls off at an unusually early "period. 

Occasionally there is observed in the course of cow-pox a papular erup- 
tion over the body of the child. This occurs usually between the ninth 
and twelfth days. 

It is quite common for the disease to be retarded in its progress. The 
delay generally takes place in the appearance of the vesicle, this not 
showing itself until the sixth or eighth day, or, in some rare instances, 
not until the sixteenth, or even the twentieth, or forty-sixth day. The 
longest retardation that we have met with has been seven days. In this 
kind of retardation, the disease usually runs through its regular and nat- 
ural phases after the vesicle has once made its appearance. In another 
kind of retardation the delay occurs in the vesicular and pustular stages 
of the affection, the papule appearing at the ordinary time, but the disease 
not reaching its height or maturitj 7 " until the eleventh or twelfth day. 

The forms of variation from the ordinary course of cow-pox just de- 
scribed, do not seem to be connected with any diminution in the pro- 
tective power of the disease. 

It sometimes happens that the operation of vaccination gives rise to a 
disease totally unlike the true vaccine disease, one which does not protect 
against small-pox, and which has therefore been called spurious vaccine 
disease. 

It was formerly the custom to describe quite a variety of appearances 
as indicating with greater or less probabilhVv a spurious disease. Of late 
years, however, it is generally admitted that the spurious pock is of much 
less frequent occurrence than was at one time supposed, and that when 



766 VACCINE DISEASE. 

it does occur, its characters are so marked as to make it eas3 r of recog- 
nition. In fact, it happens in a very large majority of cases, that the vac- 
cination either fails entirely, the puncture being productive of no other 
results than those which would naturally flow from a slight wound of the 
skin, or else that it is followed by a true and easily recognized vaccine 
pock. 

When, however, the operation is followed immediately or within a day 
or two days b} r inflammation, and the appearance of a pustule, without 
the previous production of a vesicle; when this pustule is irregular in 
shape, yellow in color, acuminated, easil} 7 broken, and terminating in a 
soft, yellowish, ragged-looking crust, which falls oft' upon the fifth, sixth, 
or seventh clay, there is assuredly reason enough to call the vaccination 
spurious, and it becomes the imperative duty of the practitioner to regard 
it as such until subsequent and repeated trials with other and fresh virus, 
have proved the child to be protected. 

Diagnosis. — There can be no difficulty whatever in distinguishing the 
vaccine disease when it occurs in its regular form. The successive phases 
through which the eruption passes, and the particular appearances which 
it presents in each stage, are so unlike all other diseases, except, indeed, 
small-pox, as to render it very easy of recognition. 

Sometimes, however, there is a little difficulty in determining whether 
the eruption is spurious or regular. But this rarely happens except under 
circumstances in which we should expect some modification in the phe- 
nomena of the disease, to wit, when its course is interfered with by the 
effects of a previous vaccination, or of an attack of variola. The irregu- 
larities arising from these causes are such as might be anticipated, and 
will be described in the article on revaccination. Whenever, however, 
the disease fails, in any important respect, to exhibit the perfect attributes 
of a well-marked pock, both as regards its time of development, its 
changes, and its particular appearances at each stage, in a child not pre- 
viously vaccinated, nor having had small-pox, the onfv wise and prudent 
plan to follow is to repeat the operation a few weeks after the doubtful 
one, so as to test therebj^ the protective power of the first. 

Protective Power. — Though vaccination has not proved so sovereign 
a means of protection against variola as it was at one time hoped it would, 
we have always thought that those who deny, or even question in a serious 
way, its incalculable benefit to the human race, as some have recently been 
found to do, deserve to be classed amongst the blindest and most unphilo- 
sophical, or worse still, the most ungrateful of mankind, for thus refusing 
to a kind Providence that meed of earnest gratitude which thej^ undoubt- 
edly owe. For, though a single vaccination may fail to afford perfect 
immunity against variola, the attacks of the disease which follow even a 
single Vaccination, are, in a large majority of cases, neither dangerous 
to life, nor followed by deformity of any kind. Moreover, a primary 
vaccination almost always affords perfect protection up to the age of pu- 
berty, thus preserving our race from a loathsome and dangerous malady, 
precisely in that period of life during which nearly all diseases prove 
most inimical to life. When we consider, too, that recent observation 



PERIOD OF PERFORMANCE — SUSCEPTIBILITY. 767 

has shown that the practice of revaocination somewhere about the age of 
puberty, or soon after, has almost always been sufficient to restore to the 
constitution that exemption from small-pox which ma}^ have been more 
or less diminished after a primary vaccination performed in infancy, our 
admiration and appreciation of Jenner's discovery cannot but be raised 
still higher. 

Period of Performance. — The period usually chosen for the perform- 
ance of this operation, is soon after the age of three months. If, how- 
ever, the infant be exposed to the contagion of variola, it is necessary to 
perform it immediately, even upon the first day of life ; and in such cases 
the protective power is as perfect, and the local or constitutional irrita- 
tion little greater, than when the operation has been deferred to the usual 
time. 

Susceptibility to the Disease. — The susceptibility to the vaccine 
disease varies greatly in different persons and different families, and is 
modified to a greater or less extent by the existence of other diseases in 
the individual at the moment of the operation. In some it is said never 
to be received, no matter how frequently or how carefully the virus may 
be inserted. In others it is received with difficulty, requiring several 
repetitions of the operation before it can be made to take ; whilst in yet 
another class of subjects, the smallest amount of virus, when inserted in 
a careless and imperfect manner even, will produce the disease with the 
greatest certainty. It may be safely asserted, however, that a large 
majorit}' of children take the disease after a single operation, if this be 
performed with ordinary care and nicety. No explanation of the differ- 
ent susceptibilities of individuals to the disease can be given. The same 
difference is known to exist in regard to other contagious and even epi- 
demic diseases, as measles, scarlatina, pertussis,, variola itself, t3 r phoid 
fever, and cholera. 

The susceptibility varies also in the same person at different times, 
without its being possible to ascribe this fact to any evident cause, since 
the child may appear on both occasions to be in the same condition as to 
health and other circumstances likely to influence its susceptibility to the 
contagion. Thus, we knew a child a few months old to be vaccinated 
four times, twice by the late Dr. C. D. Meigs and twice by one of our- 
selves, each operation following rapidly the preceding one, without suc- 
cess, though the virus was known to be good from its having succeeded 
in other subjects, and though it was changed each time. The child ap- 
peared to be in perfect health. There was no eruption of any kind upon 
its surface, nor any other condition that could explain its insusceptibility. 
After the fourth operation, the attempt was suspended for about four 
months, then renewed, and with instant and entire success. In another 
case, the varying susceptibility of the same individual to the disease was 
still more strikingly exemplified. An infant, a few months old, was vac- 
cinated four times in succession from the scab without success. It was 
then vaccinated with fresh lymph taken from the arm of an infant who 
was undergoing the disease. This also failed. A few weeks after this, 



768 VACCINE DISEASE. 

the operation was again performed with the dried scab, and this time 
with perfect success. 

Certain eruptions existing previously upon the surface, have seemed to 
us to prevent the reception of a vaccination. The eczematous and im- 
petiginous diseases of infancy and childhood have certainly had this 
effect in our experience, though M. Taupin {Diet, de Medecine, t. xxx, p. 
406) is of the contrary opinion; he having found that the disease has 
been merely retarded when the operation was performed during the ini- 
tial stage of the eruptive fevers, whilst its course was suspended even 
entirely when any of these affections occurred in a child already vaccin- 
ated, to be resumed again after the cure of the eruptive fever. 

There is another circumstance concerning the supposed effects of other 
diseases on the vaccine affection, to which it will be well to draw atten- 
tion. We are sure there are few practitioners, having any considerable 
amount of business, but must have been anno} T ed, and injured perhaps in 
their reputations, by the notion so prevalent in the community that vac- 
cination ma}^ impart to children other diseases. This prejudice exists 
particularly in regard to the chronic cutaneous eruptions of infancy and 
childhood, so that we have frequently had parents to insist to us that the 
impetiginous or eczematous disease under which their child might be 
laboring, has been caused by the vaccination, performed perhaps recently, 
or even months before. M. Taupin, quoted by MM. Guersant and Blache 
{Diet, de Med., t. xxx, p. 414) vaccinated a large number of children at 
the Children's Hospital in Paris, with virus taken from subjects affected 
with itch, scarlatina, measles, varicella, varioloid and variola, rachitis, 
scrofula, tubercles, chronic eruptions of the scalp, dartres, &c, without 
communicating to the patient any of these affections, either those of ac- 
knowledged contagious or non-contagious nature. A very curious case 
illustrative of this point is mentioned by Dr. Gregory in his " Lectures on 
the Eruptive Fevers 71 (xim. eel., New York, p. 270). U A child, who had 
been exposed to the infection of small-pox, was vaccinated. Both dis- 
eases advanced. A lancet charged with lymph from the vaccine vesicle 
produced cow-pox. Another lancet charged with matter from a variolous 
pustule, formed within the vaccine areola, communicated small-pox." 
We mention the result of these experiments in order to show how little 
foundation there is for the popular notion above alluded to, and to give 
to the practitioner an argument with which to defend himself against the 
unjust accusations of those who may assert his vaccination to have been 
the cause of any disorder that may have follow r ed upon it. Not that we 
would ourselves employ virus taken from a child suffering from disease 
of any kind whatsoever, since this is, to say the least, unnecessary, and 
ought to be avoided. Indeed, we have never employed a vaccine crust 
taken from a child who was not apparently in perfect health. The smallest 
amount of cutaneous eruption upon a child has alwa}^ been sufficient 
reason with us to reject the virus afforded by such a patient, and as this 
must be the safest plan to adopt, it is of course the proper one. 

The still'more serious charge has, of recent } T ears, been made against 
vaccination, that it may be the means of transmitting constitutional 



OPERATION. 769 

syphilis. And there are well-authenticated cases in which the operation 
has undoubtedly been followed by this terrible result. In every instance, 
however, so far as we are aware, in which the exact mode of the vaccina- 
tion could be ascertained, it has been found either that the child from 
whom the virus was obtained, presented at the time evidences of constitu- 
tional syphilis, or that the virus had been impure, being mixed with blood 
or pus, which ma}' have been the medium of infection. There is, indeed, 
no evidence whatever to show that the lymph or crust derived from a typi- 
cal vaccine eruption, in an apparently healthy child, can possibly be the 
means of transmitting any constitutional disease. It is more prudent, 
however, that if the lymph be used, it should not be taken after the eighth 
day of the existence of the vesicles ; and that in obtaining it, all hemor- 
rhage should be avoided. 

Operation. — The form in which the virus is introduced, varies accord- 
ing to the practice of individuals. 

The lymph may be inoculated from arm to arm, though of course this 
mode is but rarely available, or the lymph may be taken from the vesicles 
before the eighth or ninth da} T , and preserved on ivory points, or in sealed 
capillary tubes. 

In this cit} T , however, the crust is usually employed, and has been found 
entirely efficacious and satisfactory. As, however, there is more danger 
of employing inactive or impure virus in this form, than when lymph 
is used, it is necessary to be assured that the crust has been obtained 
from a typical case of vaccine disease in a healthy child, and that it 
should present certain plrysical characters. Thus the crust should be 
hard and brittle, slightly translucent, of dark, yellowish-brown color, and 
its under surface should usually present little depressions and ridges cor- 
responding to those described on the cicatrix. 

Different methods of inserting the vaccine virus have been employed 
by different practitioners. The two methods most frequently resorted to 
are those by incision and puncture. The former consists in making a 
superficial incision of several lines in length into the skin, in such a way 
as to cause a very slight effusion of blood. Into this is introduced a 
small quantity of a dried vaccine scab reduced to a fine powder, or a 
piece of fine thread wet with the vaccine fluid or with water holding in 
suspension a portion of dried virus. Over the wound is then placed a 
piece of isinglass plaster, which is secured by a bandage. This is to be 
removed after two or three days, and the disease allowed to pursue its 
regular course. The operation by puncture is performed by introducing 
horizontally beneath the skin a needle or lancet charged with the virus, 
and then withdrawing it in such a way as to leave the virus in the wound. 
Of these two modes the latter is the one now most frequently adopted, 
the former having been found to occasion, not unfrequently. a spurious 
disease, and to be of very difficult application in the cases of children. 
For our own part we have used for some years past a method that we have 
found much the most convenient in children, and which rarely fails when 
it is carefully performed. We take a common thumb lancet, which should 
not be too sharp. Holding the arm of the child with our left hand, and 

49 



770 VACCINE DISEASE. 

stretching the skin between the forefinger and thumb, whilst the under 
part of the arm is grasped by the second finger placed beneath the first, 
we lay the lancet flat upon the skin, and using the point, remove, by a 
repeated and very gentle rubbing movement, the cuticle, until the surface 
of the derm is laid bare, so as to allow of a perceptible, and merely per- 
ceptible oozing of blood, or, in other words, so as to expose a living sur- 
face. This surface should be about as large as a small-sized bird-shot, 
and it should not bleed, but merely show that the vascular part of the 
derm has been reached and slightly exposed. On this surface the vac- 
cine fluid or dissolved scab is to be placed in quantity sufficient to cover 
it, and the nurse should be told to leave the arm bare and untouched for 
twenty minutes, or until the applied fluid has dried into a little scab, 
when no further precautions are necessaiy. This mode of operating may 
at first seem tedious and painful. We can only say that when performed 
gentry and gradually, it causes so little pain that we have often practised 
it upon sleeping children without waking them. 

It was at one time thought necessary to make several punctures in 
order to insure a successful inoculation, some making two, and others as 
many as five ; and it appears from statistics on this point, that the sub- 
sequent mortality from variola is in an inverse ratio to the number of 
vaccine cicatrices. 1 In this city one only is generally made, and is' found 
to answer every purpose. When, however, there has been any difficulty 
in making the child take the disease, we have on several occasions suc- 
ceeded better by making two insertions, one being situated about half an 
inch or an inch below the other ; nor have we found that the local inflam- 
mation or general s3 T mptoms have ever been severe enough to cause us 
to regret this mode of operating. 

The place usually selected for the operation is, as every one knows, on 
the arm, close to the insertion of the deltoid muscle. This is the best place 
as a general rule, and particularly in girls, whose parents often object to 
having the insertion made below this, lest the scar should be visible in 

1 The protective power of vaccination, as well as the influence exerted by the per- 
fection and the number of the insertions, as shown by the cicatrices, is remarkably 
well exhibited in the following table quoted by Dr. Seaton (Art. Vaccination, in Eey- 
nolds's Syst. of Med., vol. i, p. 499), from Mr. Marson. The table is based upon 
15,000 cases. Of these it was found that the unvaccinated died at the rate of 37 per 
cent., and the vaccinated at the rate of only 6^ per cent. 

Classification of Patients Number of Deaths, per cent, 

affected with Small-pox. in each class respectively. 

1. Unvaccinated, .......... 37. 

2. Stated to have been vaccinated, but having no cicatrix, . 23.57 

3. Vaccinated. 

a. Having one vaccine cicatrix, ..... 7.73 

b. Having two vaccine cicatrices, . . . . .4.70 

c. Having three " " ..... 1.95 

d. Having four or more vaccine cicatrices, . . . 0.55 

a. Having well-marked cicatrices, 2.52 

0. Having badly-marked " 8.82 

4. Having previously had small-pox, 19. 



REVACCINATION. 771 

after years, when the arm is uncovered. In boys we often select the radial 
edge of the forearm some two inches below the elbow, since in this place 
the pock is least apt to be injured in the act of dressing the child, or of 
lifting it about. 

EEYACCINATIOjS". 

That the prophylactic influence of a primary vaccination is diminished, 
and in some instances entirely lost, by the progress of time, has been 
most positively and clearly shown by the observations of latter years. 
To prove the truth of this it is merely necessary to state, that almost all 
recent writers on the vaccine disease recommend a recourse to revaccina- 
tion some 3-ears after the first operation. With the view of bringing this 
matter fairly before the reader, we will quote the opinions expressed by 
some of the leading authorities of the day. 

Dr. Gregory (Joe. cit., p. 346) says : " The practice ma}^ be recom- 
mended for its safetj T , even if it be much less serviceable than the Ger- 
mans contend for. We have sufficient facts before us to state that it need 
never be recommended prior to the tenth year of life, and that the age 
best fitted for it is from the period of puberty to that of confirmed man- 
hood." Guersant and Blache {Diet, de Med., 2eme ed., t. iii, p. 435) have 
revoked their first opinion that revaccination was unnecessary, and state 
that they now believe firmly "that the protective power of vaccination 
becomes enfeebled and does not preserve the individual from contracting 
variola in a more or less favorably modified form ; and that in consequence 
revaccination ought to be zealously recommended and propagated." The 
Academy of Medicine of Paris, consulted by government upon this ques- 
tion some years since, determined that revaccination was unnecessary. 
In February, 1845, however, the same learned body, after reconsideration 
of the matter, arrived at different conclusions. Two of these we shall 
quote. " Revaccination is the only method of proof which science pos- 
sesses of distinguishing persons who have been definitely protected by 
vaccination from those who are so only in various degrees." 

" The trial by revaccination does not constitute a certain proof that 
those of the vaccinated in whom it succeeds were liable to contract 
variola, but only a tolerably strong presumption that it was amongst them 
particularly that the disease would have been apt to occur. In ordinary 
periods revaccination ought to be performed after the fourteenth year of 
life; when the disease is epidemic, it is prudent to resort to it earlier." 
(Guersant and Blache, loc. cit., p. 436.) 

MM. Rilliet and Barthez say (t. ii, p. 538): " The diminution of the 
protective power of vaccination, after a certain number of years, seems to 
be positively proved, but it is proved also that this diminution is almost 
nothing during the period of life which concerns us." Dr. Condie says 
(Bis. of Children, 2d edit., p. 466) : " If, therefore, the facts upon record 
are perfectly accurate, and there is no reason for suspecting them to be 
otherwise, they afford conclusive evidence of the necessity and importance 
of revaccination, in all cases in which persons are liable to be exposed to 
the infection of small-pox." It is scarcely necessary to remark that all 



772 VARICELLA. 

individuals residing in a district in which the disease is prevailing, are 
exposed to the infection, and, therefore, according to the above quotation, 
all ought to be revaccmated, which is what we are seeking to establish. 
Dr. George B. Wood, to whose work on medicine we would refer the 
reader for a very accurate and full account of vaccination and revaccina- 
tion, terminates his remarks on the latter subject with the following para- 
graph: "In concluding the subject, I would again strongly urge the 
propriety of universal revaccination, as the means not only of promoting 
the comfort and possibly of saving the life of the individual, but also of 
preventing the spread of small-pox, and of ultimately eradicating it, if 
not from the globe, at least from extensive communities." 

We might quote, in further proof of the propriety and necessity of 
revaccination, many other evidences emanating from various sources, but 
with the following short account of our own experience in regard to it, 
we shall bring our remarks to a close. In the } T ear 1845 one of us revac- 
cinated 63 persons, of whom 9 had the disease with every appearance of 
regularity ; that is to say, the puncture did not become irritated until the 
third or fourth da} r , the vesicle was perfect on the ninth, with the umbili- 
cated centre, hard base, and scarlet areola, and after that period the in- 
flammation subsided rapidty. Of these 9, all but one had characteristic 
cicatrices of previous vaccinations on the arm. The ninth was doubtful, 
but the individual insisted that he had been properly vaccinated. Of the 
remaining 54 cases, the great majority presented more or less strongly 
marked signs of the disease. In nearly all a j^ellowish pustule was formed 
some time during the second day, which was surrounded by an irregular 
patch of redness of small extent, presenting often a dotted or marbled 
look. In some the appearances promised a regular vaccine vesicle for 
several days, but terminated suddenly by the drying up of the vesicle, 
and the formation of an ill-shaped acuminated scab, which soon fell off, 
leaving a slight scar quite different from that of a primary vaccination. 

The only remaining point for consideration is the period of life at which 
revaccination ought to be performed. The prevailing opinion seems to 
be, that somewhere about puberty is the most suitable time, unless in the 
cases of children exposed immediately to the infection of the disease, 
when it may and ought to be resorted to at a much earlier period. 



AKTICLE Y. 

VARICELLA. 

Definition ; Synonymes ; Forms. — Varicella is a contagious eruptive 
disease of benign nature, characterized by more or less numerous trans- 
parent vesicles following rapidly upon small red elevations. The eruption 
is usually preceded by slight initial symptoms lasting from one to two 
days, and it terminates by the desiccation of the vesicles about the fifth 
or eighth claj^ after their appearance. 



SYMPTOMS. 773 

It is known also in English by the names of chicken-pox, swine-pox, 
and erystalli. 

Several different forms of the disease have been described by different 
writers under the titles of lenticular, conoiclal, and globular; but inas- 
much as these varieties are of no real importance in practice, we shall 
merely advert to them casually in our account of the eruption. 

Causes. — Varicella is propagated in two ways ; by contagion, and by 
epidemic influence. That it is contagious there can be no doubt, since 
nearly all observers agree upon this point. In our own experience we have 
seldom known any child, who had not had the disorder previously, to 
escape it when once it has entered a household. It rarely attacks any 
but children. Its epidemic nature is shown b}^ the fact that in some sea- 
sons it is scarcely seen, whilst in others it prevails extensively over large 
districts of country, and attacks many children in the great towns and 
cities of those districts. Varicella occurs only once in the same individual. 

Considerable discussion has taken place at various times as to the real 
nature of varicella, some asserting that the disorder is merely one of the 
varieties of modified small-pox, while others maintain as strenuously that 
it is an independent and specific disease. The weight of authority, how- 
ever, seems to be clearly in favor of the last-mentioned opinion, and we 
have no hesitation in avowing this to be the conclusion to which our own 
reading an d experience has brought us. When we consider, indeed, that 
varicella is, unlike either variola or varioloid, incommunicable by inocu- 
lation, that it attacks indifferently the vaccinated and unvaccinated, that 
its course is entirely unaffected by previous vaccination, and that the 
vaccine disease is readily taken, and passes through its regular phases 
after varicella, we do not see how we can refuse to believe that the latter 
is something entirely independent of small-pox, and therefore a distinct 
and peculiar malady. 

Symptoms; Course; Duration. — The eruption is usually but not al- 
ways preceded by prodromic symptoms. These seldom last more than 
one, or at most two days, and consist at the very beginning of slight chil- 
liness, or of a chill even, which is followed by a more or less marked 
febrile reaction. In some instances there is vomiting, but this is rare, 
and when it does occur, slight. When fever exists it is marked by head- 
ache, accelerated pulse, slight warmth of the surface, pain in the back 
and limbs, languor, indisposition to play, some unusual irritability of 
temper, diminution or loss of appetite, and unusual thirst. These s} r mp- 
toms may be present, and yet in so mild a shape that the child shall show 
no disposition to abandon its ordinary habits of activity and pla}-, while 
in other cases again, there are literally no initiatory symptoms whatever, 
and the appearance of the eruption is the first declaration of the presence 
of the malady. Even when constitutional symptoms are present, they 
usually disappear by the third day. 

The eruption appears in the form of small papular spots, of a deep red 
color, and irregularly circular shape, which generally show themselves 
first on the front and back of the trunk, and extend very soon to the face. 
and a little later, to the extremities. We have known a child to go to 



774 VARICELLA. 

bed at night with slight headache and fever, and present a well-marked 
though not yet abundant varicellous rash upon the upper part of the 
trunk, and on the face, on the following morning. These papules exhibit, 
in the course of a very few hours, small vesicles in their centres ; indeed, 
according to some observers, the eruption is vesicular from the very 
beginning. On the second day the papules are in great measure con- 
verted into vesicles, which inay be either small and acuminated, con- 
stitutiug the lenticular form of the disease, or the}* may be larger and of 
a more globular shape, constituting the conoidal and globular or globose 
forms of Willan and Bateman. We deem it unnecessary, as above stated, 
to describe different varieties of varicella, since this is useless for any. 
practical purposes, and because we constantly see upon the same subject 
vesicles of very different shape and size. When fully completed, the 
vesicles are often of very considerable size, — two or three lines in diam- 
eter; the}' contain a transparent fluid, which is either entirely colorless 
or of a faint orange tint, and some of them are surrounded by a small 
ring of inflammation. On the third da}", the eruption continues in nearly 
the same state as on the second, except that the fluid contained within 
the vesicles assumes a yellowish appearance, owing to its passage from 
the serous into the purulent condition. On the fourth da}* the process of 
desiccation begins and goes on rapidly, the vesicles that have not been 
broken by accident, or torn by the fingers of the child in its efforts to 
appease the itching which they give rise to, assuming a shrivelled and 
shrunken appearance at their margins. As this process goes on, the 
vesicles are gradually converted into light brownish scabs, so that by the 
sixth day they are nearly all dried up. The scabs are usually thin ; they 
dry from the circumference to the centre, and between the eighth and 
ninth day fall off, leaving behind faint red spots, not depressed below the 
general surface, and which soon disappear. 

The eruption is generally accompanied, as was stated aboA r e, by a sen- 
sation of heat and itching in the vesicles, which causes the child to rub 
and scratch them in such a way as often to break those which he can 
reach, and thus prevent them from passing through the regular periods 
of maturation and desiccation. 

Diagnosis. — There is but one disease with which varicella could be 
confounded, and that is variola in some of its shapes. With regular 
small-pox such a mistake could scarcely happen even to the inexperi- 
enced. With varioloid, on the contrary, there might be some difficulty, 
and yet, if it is borne in mind that in varioloid the initiatory fever is 
much more severe, lasting three or four days instead of twelve or thirty- 
six hours, that the eruption appears first on the face and extends very 
slowly to the trunk and extremities, and that the conversion from the 
papular into the vesicular condition is much more gradual than in chicken- 
pox, we think no serious difficulty can ever occur in making the distinc- 
tion between the two affections. 

Prognosis. — The prognosis is always favorable. The only real trouble 
that we have ever known to occur has been from catarrh or pneumonia 
contracted by imprudent exposure during the convalescence. 



TYPHOID FEVER — CAUSES. 775 

Treatment. — In a large majority of the cases, varicella requires no 
treatment beyond attention to diet for the first two or three days, and the 
avoidance of cold during the convalescence. When the constitutional 
symptoms are marked, the fever and headache being considerable, a dose 
of some mild cathartic, a little sweet spirits of nitre in cold lemonade or 
orangeade, rest in bed, and one or two foot-baths, will be all that is neces- 
sary to reduce these symptoms and make the patient comfortable. 



AETICLE YI. 

TYPHOID FEVER. 

It is only of late 3 T ears that the frequent occurrence of typhoid fever 
in young children has been fully recognized by medical authors. From 
the date of the publication of the classical work of Louis on this disease, 
until the year 1839, it appears to have been the almost universal belief 
that it was an affection limited to adult life ; and with the exception of a 
few brief and vague descriptions, which evidently referred to this dis- 
ease, though other names were used to designate it, medical literature 
contained no account of typhoid fever as it occurs in childhood. In the 
latter part of 1839, however, Rilliet {These de la Faculte, 1840; and 
Maladies des Enfants, t. ii, pp. 663-139) and Taupin {Journal des Con- 
naissances Med.- Chirurgicales) published separate and independent me- 
moirs on this subject ; and since that time the occurrence of typhoid 
fever in children has been frequently observed and very carefully studied. 

The fact that it was so long overlooked, is undoubtedly to be explained, 
in great part, by certain peculiarities which the disease presents in chil- 
dren, which caused its real nature to be mistaken, and led to the applica- 
tion of other names. 

Of these names, that of infantile remittent fever was the most fre- 
quently used, and though this term was made to include a number of 
other diseases, and although remittent fever does occur in children, there 
can now be no doubt that a large proportion of the cases so styled, were 
in reality cases of typhoid fever. 

Causes. — Age. — Typhoid fever has been observed during the first year 
of life, but is rare under the age of two years. It is comparatively fre- 
quent^ between the ages of three and eight years, and it attains its maxi- 
mum of frequency in childhood between the ages of eight and eleven 
3^ears. 

Sex. — The statistics of most authorities show a preponderance, more 
or less marked, of cases occurring in boys. In some series of cases this 
disparity has been remarkable (three to one) ; but, notwithstanding, it is 
probable that in a very extensive series the difference would be compara- 
tively trifling. 

Contagion. — It can scarcely be doubted that typhoid fever is occasion- 



776 TYPHOID FEVER 

a\\y transmitted by contagion, "but the degree of its contagiousness is 
extremely slight. On the other hand, it is subject both to epidemic and 
endemic influences in a marked degree; and it is owing to the varying 
action of these causes that it presents the wide variety, in type and 
severity, which will be described. 

Anatomical Appearances. — These are strictly analogous to those 
found in the adult. When death occurs early in the attack, the agminate 
glands of the ileum are found swollen, prominent, injected; the altera- 
tion being most marked in those nearest to the ileo-coecal valve. Later, 
however, these glands ulcerate, the softening beginning either on the sur- 
face, and extending more and more deeply, or beginning in the deeper 
portion of the patch, so that the superficial layer may be thrown off as a 
slough. 

These ulcers thus destroy the mucous membrane, and present the sub- 
mucous or muscular coats for their base ; or, in some instances, the ulcer- 
ative process may extend through the muscular and even through the 
peritoneal coats. 

According to Rilliet (loc. czY.), however, these ulcers are more slow in 
forming, smaller, and less numerous and deep in children than in adults; 
and, indeed, he believes that in not a few instances the swelling and in- 
flammation of the gland may undergo resolution without the occurrence 
of ulceration. 

Too much importance must not, however, be attached to this state- 
ment, since it appears to us evident that a few cases, at least, of typhus 
fever are included amongst those upon which his memoir is based. 

The solitary glands are, in the early stage of the disease, prominent, and 
may be distended with a serous or more thick and yellowish secretion, so 
as to resemble vesicles or even pustules. Later in the attack their mu- 
cous covering is destroj-ed, and small, round, or oval ulcers, with everted 
edges, remain. These ulcers are also most numerous in the lower part 
of the ileum, though in some cases they are met with quite abundantly 
in the large intestine. 

The mesenteric glands are enlarged, softened, and strongly injected, 
the change corresponding in intensit}^ to that of the agminate glands in 
the ileum, and being most marked in those glands which are nearest the 
ileo-ccecal valve. Usually the swelling of these glands subsides without 
suppuration occurring, but occasionally this ensues, and the gland is 
converted into an abscess with thin walls. 

The cicatrization of the intestinal ulcers appears usually to occur rap- 
idly; thus, Rilliet has seen the process completed by the thirtieth clay, 
though this is probably sooner than it is entirely finished in the majority 
of cases. 

Ulcers of other mucous surfaces, as of the pharynx and larynx, are 
more rarely met with in children than in adults. The spleen is nearly 
alwaj^s considerably enlarged and softened. 

The blood in severe cases is dark and uncoagulable, and the lining 
membrane of the heart and large vessels is stained by imbibition. In 
some cases quite firm coagula are met with in the cavities of the heart. 



SYMPTOMS OF ORDINARY CASES. 777 

Even in cases where the most violent nervous symptoms have been 
present, the brain rarely presents any more positive lesion than mere 
congestion of the vessels of its membranes and substance, with at times 
some subarachnoid effusion. In some cases where death has occurred some 
time after the termination of the fever itself, but where cerebral symp- 
toms have persisted, tubercular meningitis has been found, and it has 
been thought that the irritation of the brain during the fever was the ex- 
citing cause in a system strongly predisposed to a tubercular develop- 
ment. 

Symptoms. — The general course of typhoid fever is much the same in 
children as in adults. 

It presents also the same wide variety in its type and degree of severity, 
depending upon the predominance and excessive development of some 
one of the elements of the disease ; and it would be easy, therefore, to 
divide the disease into a great number of forms, according to the promi- 
nence of each functional disturbance; but as our object is merely to give 
a practical description of the disease as met with in children, we will, in 
considering its course, give a brief sketch of an ordinary case, and then 
dwell in detail upon certain symptoms which require special notice, as 
presenting peculiarities in childhood. 

In the majority of cases, the attack is preceded for some days by slight 
prodromes; the child, who ordinarily may enjoy robust health, appears 
languid, and is easiby tired, and indisposed to play ; he loses his appetite, 
is restless during sleep, and possibly may complain of colicky pain in the 
abdomen, perhaps attended with slight looseness of the bowels. After this 
state of vague indisposition has lasted from three or four to eight or ten 
days, more decided symptoms manifest themselves, and the attacktmay 
be said to fairly begin. 

More or less febrile action now appears ; but this is rarely continuous, 
and for the ensuing five or six days there are distinct and marked remis- 
sions, usually in the morning, but sometimes so marked and prolonged 
that it is only towards night that the skin becomes heated, the pulse fre- 
quent, and the child grows restless, while, during the day, he has merely 
appeared somewhat dull and languid. The loss of appetite continues, 
and becomes more complete, though thirst is marked ; vomiting is apt to 
follow eating, and is sometimes frequent and spontaneous ; the tongue 
presents a moist, whitish-yellow fur in the centre. The bowels either 
continue loose, or now become so for the first time; the abdomen be- 
comes somewhat large and tympanitic, and slight tenderness may be 
present in the right iliac region towards the close of the first week. 

The strength is rapidby lost, and the child, after the first few days, 
shows no desire to leave the bed. The respirations are somewhat hurried, 
and are often accompanied by sonorous rales and slight dry cough. The 
pulse is accelerated, but rarely rises at this stage above 110. 

The expression grows dull and listless, unless temporarily excited 
during delirium, and the child takes but little notice of surrounding per- 
sons or objects. During the night there may even now be a tendency to 



778 TYPHOID FEVER. 

more marked cerebral disturbance, and the little patient grows very rest- 
less, utters sharp, shrill cries, or talks unmeaningly. 

About the end of the first week the characteristic eruption appears, 
first on the upper part of the abdomen, in the form of small, flat, oval 
spots, of a light rose color, disappearing on very slight pressure, and quite 
rap i clly r eturni n g. 

During the second week the symptoms become more severe. The 
fever is more continuous, and the temperature ranges in different cases 
from 102° to 105° ; it ma}' still present, however, decided morning re- 
missions, and it is not rare for profuse warm perspiration to occur, with- 
out having any critical value whatever. The pulse becomes more fre- 
quent, 120, 140, even 160, and at the same time smaller and of less force. 
The respirations are also more hurried, and, when the pulmonary com- 
plication is marked, may be very rapid and shallow, and the cough fre- 
quent and annoying; in such cases, auscultation reveals, especially over 
the postero-inferior part of the lungs, abundant mucous, or subcrepitant 
rales. The vomiting ceases, and the child will usually take the liquid 
food offered it ; the tongue becomes more heavily furred, and may be 
dry and brownish in the centre, though it often remains moist and }'el- 
lowish-white throughout. Thirst is apt to diminish, owing to dulness of 
the perceptions, but the child will frequently drink greedily of cold water 
if offered to it. The diarrhoea persists, however, and the stools are ochre 
yellow and fluid ; the belly is more tympanitic, and maj- be extremely dis- 
tended. The discharges, both of urine and fasces, are often involuntary, 
and the child does not even appear conscious of them. The urine is "high- 
colored and scanty. The eruption continues and becomes more abun- 
dant, the spots which appeared passing away and being followed by succes- 
sive crops. Sudamina are also frequently present, especially when sweat- 
ing occurs. The mind becomes more and more dull, though it is nearly 
always possible to rouse the child b}' speaking loudly to it; delirium is 
usually present, especially in the night, and manifests itself in young 
children by restlessness, sharp, unmeaning cries, and a wild expression 
of the face, and in older ones by muttering, or even by attempts to leave 
the bed. Irregular muscular movements, such as floccitatio and subsul- 
tus, are rarely noticed; though at times these, and even spasmodic rigidity 
of the trunk or limbs, or convulsions, ma}' be present. 

We have thus sketched the course of what is, perhaps, the most com- 
mon form of t} r phoid fever in children, where the disease begins gradu- 
ally, and either remains mild throughout, or assumes a more grave char- 
acter during the second week. 

In a certain number of cases, however, the onset of the disease is far more 
sudden and violent, and the severhVy of the attack is manifested from its 
earliest period. In this form, the prodromes are brief, or almost entirely 
absent ; and there may be in older children an initial chill, or the only symp- 
toms present are marked debility, languor, and drowsiness. During even 
the first two or three cla} T s, however, there is apt also to be frequent vomit- 
ing, severe headache, or marked hebetude, and high fever, which usually 
presents the same marked morning remissions and evening exacerbations 
as in the milder form. The sleep is restless and disturbed, and the child 



SYMPTOMS OF GRAVE CASES. 779 

either litters sharp cries, or, if older, talks incoherently. The pulse and 
respiration are much accelerated, and the temperature of the surface 
rapidly rises, till, by the end of the first week, it may reach 103° or 
105 c . The cerebral disturbance may mask the presence of any abdominal 
pain ; and as it is not unusual for the bowels to be quiet for the first few 
days, the case ma}' closely simulate some acute cerebral disorder. By 
the end of the first week the disease is developed in its full severity. The 
fever is more nearly continuous, the morning remissions being compara- 
tively slight, and the skin remains constantly dry and hot. There is deep 
stupor, from which the child is roused only with much difficult}'', and which 
occasionally alternates at night with restlessness, jactitation, and noisy 
delirium. The pulse is very frequent and feeble, and the breathing ac- 
celerated, and usually accompanied with bronchial rales. The vomiting 
ceases, but the abdomen becomes tympanitic, and there is more or less 
abundant diarrhoea; the stools are often passed quite involuntarily, and 
the urine is either retained or dribbles away unconsciously. Epistaxis 
occurs in a large proportion of cases, and about this time the character- 
istic rose-colored eruption makes its appearance. During the second 
week all of the symptoms become more grave, and the patient may suc- 
cumb to the violence of the disease, or remain for a week or ten days 
plunged in profound stupor, with subsultus and marked muscular tremor ; 
with the lips and teeth coated with sordes, the tongue tremulous, dry, and 
coated with brown crusts, the abdomen tympanitic, and the stools frequent, 
thin, and passed involuntarily; with the pulse running, feeble, from 130 
to 160 in the minute; the respirations shallow, imperfect, and attended 
with subcrepitant rales, indicating passive congestion of the lungs; with 
the urine retained, dark-colored, and even albuminous ; and yet gradually 
emerge from this apparently hopeless condition to enter upon convales- 
cence about the close of the third week. 

In favorable cases, between the fifteenth and twenty-first day, the grave 
symptoms begin to abate. ' The child's expression becomes more natural, 
and often the earliest sign of approaching convalescence will be the ap- 
pearance of a smile of recognition, or of pleasure at the consciousness of 
improvement. The fur upon the tongue becomes looser, moister, and 
begins to separate, and the appetite slowly returns ; the distension of the 
abdomen diminishes, and the stools are again passed consciously and voir 
untarily, and gradually assume a healthy appearance. Restlessness and 
delirium disappear, and the sleep becomes quiet and refreshing ;. the fever 
subsides, and the temperature falls, and again shows a marked difference 
between the morning and evening. The child thus passes into a state of 
convalescence, which, when not disturbed by complications, is quite rapid, 
though attended with marked emaciation, extreme debility, and feeble- 
ness of digestive power, with a tendency to intestinal disturbances. In 
some rare cases, at times without assignable cause, at others from im- 
proper exposure or exertion, or indiscretions in diet, the patient suffers 
a relapse, the original symptoms reappear, and a second fully developed 
attack of typhoid fever,, attended with marked nervous symptoms, charac- 
teristic eruption, and diarrhoea, may ensue.. 



780 TYPHOID FEVER. 

In very severe cases, on the contrary, and especially when a fatal re- 
sult is to follow, the condition of the patient grows more and more grave 
after the end of the second week, unless as at times happens, death has 
occurred sooner from the violence or malignancy of the attack. The 
nervous symptoms become more marked, aud the child siuks into a 
deeper stupor, even approaching true coma, or the stupor is interrupted 
by violent agitation, with cries or efforts to leave the bed, or by muscular 
twitchings, picking at the bed-clothes or even general convulsions. The 
pulse is very rapid and small ; the respirations hurried and noisj^, and plrvs- 
ical examination frequently reveals the existence of extensive bronchitis 
or hypostatic pneumonia. Yomiting is rarely present, but hiccough may 
be frequent and distressing; the belly is enormously distended, the stools 
frequent, involuntary, and at times bloodj^. Bed-sores form on points 
subjected to pressure, and death ensues amid profound stupor and with 
signs of extreme pulmonary obstruction. 

At other times death occurs not so much from the extreme violence of 
the disease itself as from the development of some one of the complica- 
tions which will be mentioned hereafter. 

Special Symptoms. — Although, as has been seen, the general course 
of typhoid fever is much the same in children as in adults, there are a 
few symptoms which require more detailed notice, as presenting peculiari- 
ties which impress special features upon the disease as it occurs in child- 
hood. 

Prodromes. — In children, as in adults, typhoid fever is nearly always 
preceded by a marked prodromic stage, and the passage from the state 
of health to the fully developed disease is usually very gradual. The 
duration of these prodromes varies from three or four to ten days, being 
least in the more severe cases. 

Fever. — Condition of Skin. — We have already remarked that, in the 
early stage, there are apt to be very marked remissions in the febrile 
action lasting even throughout a considerable part of the day; the exacer- 
bations of the fever usually occurring towards evening. West states 
that in some few instances two distinct remissions and exacerbations may 
be noticed in the course of every twenty-four hours. It is this feature 
which gained for the disease the name of infantile remittent fever and 
caused it to be ranked with the malarial diseases. Towards the middle of 
the second week, however, the remissions become much less marked; the 
temperature, which in some cases reaches 104° or 105°, merely present- 
ing a somewhat marked fall in the morning. The skin is hot and dry as 
a general rule, but sweats are more apt to occur during the height of the 
disease than they are in adults ; the} r are not, however, of any prognostic 
value. 

Digestive Symptoms. — Among the earliest and most important symp- 
toms are various disturbances of the digestive functions. The appetite 
rapidly fails, and is often lost before the attack fairly begins. Thirst is, 
however, marked until dulness of the mind appears, after which it also 
may be entirely absent, though the child will usually drink if cold water 
be offered to it. The tongue is always furred, usually being covered 



SPECIAL SYMPTOMS. 781 

throughout the course of the disease by a thick yellowish-white coat, 
which inay remain moist and loose, or in very grave cases, becomes dry 
and brownish. Sordes are not often observed. Vomiting, which is per- 
haps not more frequently met with in the early stage in children than in 
adults, may be very frequent and persist until far into the second week. 
In the majority of cases, diarrhoea is either present or the bowels are 
peculiarly sensitive to the action of laxatives. In some cases, however, 
and especially those where vomiting is marked, constipation of a quite 
obstinate form is present. The conjunction of these two sjmaptoms, in 
connection with the cerebral symptoms present, may cause the case to 
strongly resemble the first stage of tuberculous meningitis ; the doubt 
may, however, be usually resolved by careful examination, as will be 
more fully alluded to under the head of diagnosis. 

The stools, when diarrhoea exists, are ochre-colored, fluid, and on stand- 
ing, deposit a sediment of shreds of mucous membrane, epithelium, and 
partially digested food. Mucus is rarely present ; but blood, in varying 
amount, may be mixed with the fecal matter. When the amount is large, 
it is usually due to the ulcerative process in the intestine having opened 
a vessel of considerable size, and then constitutes a very grave complica- 
tion. 

In young children it is difficult to establish the existence of abdom- 
inal pain, but, when they are capable of describing their sensations, 
colicky pain is frequently complained of in the early stages; and even in 
the youngest children, pressure in the right iliac region may often be 
seen to be painful. 

Tj'mpany is usually present at some time during the attack, especially 
when there is diarrhoea. Even when the bowels are confined, however, 
the abdomen is never retracted. Rilliet states that, in some grave cases, 
he observed such great tympany that the abdominal walls were thin 
enough to allow the outlines of the convolutions of the intestine to be 
clearly seen. 

Enlargement of the spleen nearly always exists, but frequently to so 
slight a degree that it cannot be readily detected either by palpation or 
percussion, and even when considerably enlarged, it is apt to be entirely 
hidden by the distension of the abdomen. 

The urine presents the ordinary febrile conditions, being scanty, high- 
colored and of high specific gravity ; the pigment is increased, and the 
chlorides much diminished. 

The stools are, as we have already said, often involuntary during the 
height of grave cases, after the beginning of the second week. Until this 
time, however, and throughout the entire course of more mild cases, the 
child is conscious of the desire, and can control the passage, or even 
wishes to be taken from the bed for the purpose. 

The urine is also, though more rarely, discharged involuntarily ; in rare 
cases, which may ultimately recover, retention of urine is present, and is 
of grave import. Rilliet never observed this symptom, but we have seen 
it more than once, and especially in a boy aged five years, who required 
catheterization for several days successively, but who finally recovered. 



782 TYPHOID FEVER. 

Eespiratory and Circulatory Symptoms. — Even during the first week, 
there is usually more or less diy cough, with sonorous and sibilant rales 
over the posterior part of the lungs. Later in the disease, and owing 
merely to the passive lrypostatic congestion of the lungs, and the accumu- 
lation of mucus in the bronchial tubes, the cough is apt to grow more fre- 
quent and troublesome, the respiration is hurried and oppressed, and aus- 
cultation reveals moist and dry rales throughout both lungs. When pneu- 
monia or bronchitis supervene, these S3 T mptouis of respiratory obstruction 
increase to a marked degree. Extreme rapidity of breathing, with alter- 
ations in its character and rhythm, are also met with, however, in cases 
where the pulmonary obstruction seems moderate, but where the nervous 
S3 T stem is profoundly disturbed. 

The jntlse is accelerated from the very first, and during the height of 
the disease, rises to 120, 140, or even 180, according to the age of the child. 
In grave cases it may become extremely small, feeble, and compressible, 
but scarcely ever is intermitting or irregular. 

The eruption of typhoid fever in children presents precisely the same 
appearances as in the adult ; it usually appears first on the upper part of 
the abdomen, and often presents several successive crops. It is, however, 
more frequently absent entirely, and presents even greater irregularities as 
to the date of its appearance, in them than in adults. The abundance of the 
eruption certainly bears no relation whatever to the severity of the attack; 
and in a varying proportion of cases (7 in 30, Hillier), the most careful 
daily examination fails to detect the characteristic spots at any period of 
the case. The eruption makes its appearance in a large majority of cases 
between the sixth and twelfth days, but the first spot has been observed 
so late as the twenty-fifth day (Hillier), or the twenty-ninth (Rilliet). 

Sudamina are frequently present in large numbers at any time after 
the ninth day. 

Epistaxis is very rarely abundant, but is met with in a majority of 
cases at some period after the third day. 

Nervous Symptoms. — In none of the s3 T mptoms of this disease is such 
variety observed as in those furnished by the nervous system. 

In mild cases, consciousness is. retained throughout the attack; the ex- 
pression of the face is stupid and hea^y ; the child is dull and disposed to 
doze during the 'day, but becomes feverish and restless towards night, and 
sleeps uneasily and wakes frequently. 

In more severe cases, the nervous symptoms soon become prominent. 
The face assumes an almost characteristic expression : the eyes are dull 
and vacant, or bright and excited during temporary delirium; the cheeks 
present a circumscribed flush ; the lips are dry and parched ; and the fea- 
tures remain almost motionless. 

Headache is sometimes complained of, and without doubt exists in 
many cases when the child is too young to call attention to it. It is 
especially observed in the early part of the attack, when there may be 
some hebetude and deafness present, and, according to Dr. Jenner, ceases 
upon the appearance of delirium. 

This latter symptom rarely appears in marked degree before the 



SPECIAL SYMPTOMS — COMPLICATIONS. 783 

second week, but then may become violent, the child crying out loudly, 
or muttering incoherently, and struggling violently to leave its bed. The 
delirium is rarely continuous but is most marked during the night, being 
replaced during the day by more or less profound stupor, which, however, 
rarely amounts to actual coma. 

Subsultus, and carphologia, as well as muscular rigidity, are compara- 
tively rarely observed in children, and only in very grave cases. Con- 
vulsions, even of a general and violent character, are met with in a very 
small proportion of cases ; they may occur in the early stages of cases 
which subsequently recover, or as one of the final phenomena in fatal 
eases. They are, however, at whatever stage they present themselves, of 
very grave import. In a case mentioned by West, the convulsions re- 
curred on two successive days at the middle of the third week of the 
fever, and were succeeded by hemiplegia, which continued, though gradu- 
ally diminishing, for four days. The child was unconscious even before 
their occurrence, and continued so for several clays, though he eventually 
recovered. 

As a general rule, the course of t} T phoicl fever is much less apt to be 
attended b} T an} T complication in children than in adults ; there, are, how- 
ever, some which occur with considerable frequency. 

We have alread3 T stated that cough and signs of slight bronchitis are 
frequent in the earh T stage. In a considerable number of cases these 
symptoms become aggravated as the case progresses, and there may 
be a development of general bronchitis or even pneumonia ; more fre- 
quently, however, the condition of the lungs is rather one of hypostatic 
congestion than of true inflammation. These complications, when present 
in a marked degree, protract the case and add greatly to its danger. 
Pleurisy is comparatively rare. 

Perforation is more rare in children than in adults ; but when present 
gives rise to the same symptoms, and leads to an equally rapidly fatal 
result. In some cases, its occurrence is announced by an attack of con- 
vulsions (Rilliet). 

Intestinal hemorrhage, on the other hand, is comparatively frequent ; 
thus Hillier observed it four times out of thirty in which the stools were 
carefully examined. It is usually of grave significance, but is at times 
seen in mild cases, which recover readily. 

Earache is not infrequently observed after the height of the disease ; 
in some cases it is followed by abundant purulent discharge. 

Inflammation of the parotid gland is much less frequent than in adults, 
as is also phlegmasia alba dolens, of which, however, there are instances 
on record. 

There is very little tendency to the formation of bed-sores in children, 
and with care in the management of the patient, they will scarcely ever 
occur. In some epidemics, gangrene of other parts, as of the vulva or 
cheek, have been observed in a few instances. Angina, and occasionally 
pseudo-membranous laryngitis have also been noticed. 

We have seen that the urine is at times albuminous, and in these cases 
there is undoubtedly an intense congestion of the kidneys, which in very 



784 TYPHOID FEVER. 

rare instances eventuates in Bright's disease. (Eclema is not usually 
present, even when there is albuminuria, though Billiet records two cases 
where anasarca, accompanied by albuminous urine, appeared on the fifth 
day, and lasted about a week. When oedema appears late in the course 
of the disease, it is probably to be rather attributed to a watery state of 
the blood and the debility of the circulation. 

We have alread}^ seen that the febrile movement in typhoid fever, in 
children, presents such marked remissions, as to have led many observers 
to apply the name infantile remittent fever to the disease. We must 
bear in mind, however, that it is far from being rare for a true malarial 
element to be present, complicating the case, and constituting it a typho- 
malarial fever. 

During the height of the disease, it is rare for any of the other erup- 
tive fevers to make their appearance ; but during convalescence, variola, 
rubeola, and scarlatina, have all been occasionally observed to appear, 
and run through their regular course. 

Tuberculosis is by some regarded as one of the most frequent of the se- 
quelae of typhoid fever in childhood ; and in some cases, indeed, it appears 
as though the extreme debility of constitution induced by the disease 
favored the development of tubercle in children with hereditary predis- 
position. It is probable, however, that in some cases also the early stage 
of acute tuberculosis has been mistaken for typhoid fever, with which, as 
will be more clearly pointed out, it possesses some strong features of 
resemblance. 

Convalescence. — The convalescence is, as in adults, tedious and un- 
certain. The child often remains for many weeks in a condition of great 
debility, and with such extreme nervous exhaustion, that Irydrencephaloid 
symptoms may even be present. 

The digestive system also manifests this debility in a most marked 
degree, and it requires the greatest tact and care to encourage the child 
to eat and, at the same time, to regulate the diet, since the slightest indis- 
cretion will serve to excite serious symptoms. Not rarely death ensues 
many weeks after the termination of the disease itself, in a state of in- 
tense emaciation, the child being worn out by persistent diarrhoea, which 
resists all change of diet and treatment. 

We have already alluded to the fact, that occasionally relapses have 
been observed, either without cause or following some trifling indiscre- 
tion, in which the symptoms of the fully developed disease have reap- 
peared and gone through their regular course. 

Titration. — The duration of the fever varies according to the severity 
of the case. Even in the mildest forms it rarely begins to subside before 
the end of the second week, while much more frequently it is protracted 
until from the twentieth to the twenty-third day. In many cases, indeed, 
convalescence cannot be said to be fairly entered upon before the end of 
the fourth week. 

Prognosis and Mortality. — The symptoms and conditions which indi- 
cate a favorable or unfavorable termination to the case are the same as pre- 
sent themselves in the adult, and may be readily gathered from the fore- 



DIAGNOSIS. 785 

going description. The mortality of typhoid fever is, however, decidedly 
less in children than in adults, partly owing to the comparative rarity of 
dangerous complications, and partly to the fact that the disease is usually 
of a less severe type. In mild cases, death scarcely ever occurs ; and even 
in the more severe forms, the mortality is only from 5 to 10 per cent., 
under favorable hygienic circumstances. 

Diagnosis. — We have alread}- stated, that, partly owing to the imper- 
fect recognition of typhoid fever, and partly to the various names which 
were loosely applied to this disease as occurring in children, it was 
formerly frequently confounded with other affections. 

There are, however, several diseases from which it is not always easy, 
even with our improved knowledge of its peculiar symptoms, to distin- 
guish it. 

Thus in some cases of gastro-enteritis, such as are not rare among chil- 
dren, and especially when the disease assumes a typhoid form, the re- 
semblance to typhoid fever is so great as to have led Rilliet and Barthez 
to assert that it is impossible to make a differential diagnosis. 

It should be borne in mind, however, that typhoid' fever may often be 
traced to epidemic or endemic influence, and occasionally to contagion ; 
that it is very rarely possible to assign any direct exciting cause for the 
attack; and that it especially attacks children over five years of age, 
comparatively rarety those between two and five years, and almost never 
those under the former age. Its onset is usually more gradual ; the 
vomiting and diarrhoea are rarely so marked ; the fever is more intense, 
the loss of strength greater and more rapid; while the marked dulness 
alternating with delirium during the night, the occurrence of the charac- 
teristic eruption and of epistaxis, and the more fixed duration, form a 
group of sj'mptoms which should serve, when present, to clearly distin- 
guish these two diseases. 

In some cases the pulmonary complication, either in the form of dif- 
fuse bronchitis or of pneumonia, appears so early and causes such marked 
symptoms as tend to conceal those of the constitutional disease, and ren- 
der care necessary to avoid overlooking it entirely. 

On the other hand, it occasionally happens, and more frequently in 
children than in adults, that cases of pneumonia assume a typhoid con- 
dition, and present very many of the general symptoms of typhoid fever. 
It will, however, usually be sufficient in cases of this kind to pay careful 
attention to the early symptoms and mode of development of the disease, 
as well as to the existence or absence of the characteristic symptoms of 
t}'phoid fever, such as diarrhoea, tympany, epistaxis, rose-colored erup- 
tion, to avoid any error in diagnosis. 

In some cases of acute, general tuberculosis, in which the deposit 
affects the brain, lungs, and intestinal canal, the symptoms may closely 
resemble those of typhoid fever. This form of tubercular disease may 
develop itself in the midst of seeming good health, the child losing- 
strength and spirits; fever of a remittent type soon appearing; with 
vomiting, diarrhoea, tympanitic abdomen, and dry, furred tongue; and 
dulness of mind during the clay, alternating with delirium at night. At 

50 



786 TYPHOID FEVER. 

the same time there is cough and rapidity of respiration, though the de- 
posit in the lungs may be too slight and uniformly diffused to reveal itself 
by any positive physical signs. 

In some such cases, indeed, it is only possible to form a probable 
diagnosis, based upon the age and previous history of the child ; for 
acute general tuberculosis appears even at the earliest ages, and espe- 
cially in children who have an hereditary tendency to tubercular disease, 
or who are delicate and frail, or have lately passed through an attack of 
some one of the eruptive fevers, or of hooping-cough ; and upon the ab- 
sence of eruption and the greater duration of the case. 

Usually, however, there is a sufficient ground for diagnosis furnished 
by the special symptoms, even early in the course of the case. Thus, in 
typhoid fever the vomiting in the early stage is rarely frequent or obsti- 
nate, and only follows eating ; and, though the bowels may be constipated 
for a day or two, diarrhoea soon makes its appearance, and the abdomen 
begins early to enlarge. In acute tuberculosis, on the other hand, the 
vomiting in the early stage is usually both frequent and obstinate, and 
occurs entirely causelessly ; whilst the bowels are in most cases consti- 
pated, and the abdomen retracted until a much later period in the case, 
when the disease of the mucous membrane excites diarrhoea. The ap- 
proach of fever in the tubercular disease is more slow, its course less 
regular, and its degree less intense, as a general rule, than in t} T phoid 
fever. 

The nervous sj'mptoms in the early stage may be almost identical, but 
before long, in cases of tuberculosis, some of the unmistakable signs of 
tubercular meningitis, such as strabismus or partial paralysis, usually ap- 
pear. Epistaxis is rare in tuberculosis, and of course the characteristic 
eruption of t3 T phoid fever is absent, though it must be borne in mind that 
this is not constant in the latter disease. And, finally, though the pul- 
monary disease may in some cases be slight and not reveal itself by posi- 
tive plrysical signs, most important aid is often derived from a careful 
exploration of the chest. 

Treatment. — Typhoid fever in childhood requires the same general 
plan of treatment as in adults. In mild cases little else is required than 
strict attention to all hygienic precautions, and a supporting, but fluid 
and digestible diet. Whatever complications ensue, should of course be 
treated appropriately. There are, however, a few indications in regard 
to which it may be well to speak more in detail. 

When the fever is high, febrifuges, such as liq. ammoniae acetatis and 
sp. setheris nitrosi should be given ; to which a little syr. ipecac, may be 
added, if the congh be troublesome. The surface of the body should be 
sponged daily with tepid water, to which a little vinegar may be added ; 
or the child may be carefully lifted for a few minutes every day or every 
other day into a bath of about 65° to 15°. 

If there is much gastric irritability in the early stage, food should be 
given in very small quantities ; counter-irritation may be emphyyed in the 
form of mustard-plasters to the epigastrium ; or, if there be reason to think 
that the stomach contains undigested, irritating food, an emetic of ipe- 



TREATMENT. 787 

eacunnha may be given. If the bowels are constipated, veiy small doses 
of some mild laxative, as castor-oil or S}T. rhei aromat. should be given 
during the first week; but when spontaneous diarrhoea is present, it 
should, unless it becomes excessive, not be interfered with. When, 
however, the stools exceed three or four daily, chalk mixture, with some 
vegetable astringent and opium, or small doses of opium and acetate of 
lead, may be administered. 

In ordinary cases the nervous sj^mptoms scarcely require any especial 
attention. When, however, they become marked, it will often suffice to 
apply wet cloths to the head, and to administer warm mustard foot-baths 
to allay the agitation. In cases where delirium becomes extreme, with 
great nervous agitation, the above remedies should still be used, but, in 
addition, small doses of chloroform with camphor-water, or even of 
opium, should be given, and will often produce the happiest effect. Dr. 
West speaks highly in such cases of the combination of opium and tartar 
emetic, recommended by Graves in the treatment of the head-symptoms of 
typhus fever. 

In regard to the occurrence of complications, we have already alluded 
to the remedies by which diarrhoea is to be checked if it becomes exces- 
sive. When the symptoms of pulmonary obstruction become marked, 
frequent counter-irritation by mustard or turpentine should be applied 
to the chest, and stimulating expectorants, as carbonate or muriate of 
ammonia, administered internally. 

Hemorrhage from the bowels and peritonitis from perforation, must be 
treated exactly as in the adult, the one by astringents, either vegetable 
or mineral, the other by the free use of opium. 

Qf the special remedies which are recommended in this disease, we 
ma}^ allude to the treatment by means of mineral acids, especially the 
muriatic and nitromuriatic, which is highly praised by some authorities. 

Quinia is necessary in many cases as a tonic when adynamic symp- 
toms begin to appear ; but in some cases where the remittent character 
of the fever is marked, and where there is a suspicion that the case is 
complicated with a malarial element, it should be administered in full 
anti-periodic doses in the earliest stages. 

Opium is rarely necessary in the early part of the disease, unless it be 
required to check diarrhoea ; but when, in the latter part of the second or 
third week, the delirium becomes extreme, and the child sleeps but little, 
the night being spent in violent restless agitation, with loud screaming, 
opium should be fearlessly given until quiet sleep is produced. 

The oil of turpentine is to be administered under the same conditions 
which call for its use in adults. 

Stimulants are by no means absolutely necessary in all cases of typhoid 
fever in children. Excepting in the very mildest, however, it is prudent 
to administer them in small quantities after the middle of the second 
week. When, however, the condition of the child calls for their more 
free use, as shown by the frequent feeble pulse, rapid labored breathing, 
dry, brownish tongue, dulness alternating with nois}^ delirium, and other 
marked nervous symptoms, they should be given to the extent of f 5 iij to 



788 TYPHOID FEVER. 

f^yj of sherry wine, or even of brandy, to children of six years old. It 
will be found in these cases that even such large amounts of stimulants 
as the above are very well borne by children. 

The food should be given in small quantities, and frequently repeated. 
It should throughout the entire course of the disease be exclusively fluid, 
consisting of milk, chicken-water, or the various animal broths. It is 
rarely difficult to regulate the diet of children suffering with this disease, 
since their entire loss of appetite renders them indifferent to all food, and 
they will usually take whatever is offered to them. 

During convalescence, the utmost care must be exercised both in re- 
gard to food and exercise. Solid food should be permitted ver}< gradually, 
and with much caution ; beginning with the lightest and most digestible 
forms, and watching the manner in which each article is digested. 

In those cases where the child remains a long time in a condition of 
extreme debilit}', with impaired power of digestion, the bitter tonics and 
iron should be given, if the stomach will tolerate them. Sea, or cold water 
bathing, change of residence, and the utmost attention to all hygienic 
rules, are also to be recommended. When there is any reason to dread 
the development of tubercular disease, this treatment must be carried 
out with the greatest assiduity; and, if the child can digest it, cod-liver 
oil may be given with advantage. 



GLASS VII. 

DISEASES OF THE SKIN. 

INTRODUCTORY REMARKS. 

It will be observed that, in regard to some of these affections, we have 
altered the arrangement which was adopted in the last edition of this book, 
while retaining the same general divisions of skin diseases : rashes, pap- 
ules, A^esicular, pustular, and squamous affections. For although none 
of the new classifications recently devised, some of them based upon the 
anatomical element of the skin affected, others upon the nature of the 
pathological process present, and others still upon the clinical relations 
of the various diseases, appear to us completely satisfactory ; still the 
more rigid stmlv of skin diseases has rendered necessary the removal of 
a number of eruptions from the classes where they were formerly placed. 
We follow then the example of Wilson, who retains the original clas- 
sification of Willan, modified and expanded, however, so as to harmonize 
with the results of more recent observations. 

The class which will be found to have been most changed, is that of 
vesicular diseases, of which eczema, a disease formerly defined to be 
characterized by the presence of vesicles, was the type. It was long ago 
evident, however, that this was not a strictly correct definition, since in 
many cases of eczema, other elements of eruption besides the vesicles were 
present. And, accordingly, the term eczema is no longer restricted to a 
purely vesicular eruption, but is erected into a generic title for all affec- 
tions which are characterized by redness, itching, infiltration of the skin, 
exudation on its surface, and the formation of crusts, whether the ele- 
mentary lesion be an erythematous rash, a papule, a vesicle, or a pustule. 
In accordance with this, as will be seen more in detail under the head of 
eczematous affections, this class includes many cases of some affections, 
as impetigo, which were formerly classed among the pustules, and of 
others which were included among squamous diseases. 

It would be worse than useless in a work like the present, which is 
necessarily restricted within certain limits as to size, to attempt a full 
description of all the diseases of the skin to which children are subject. 
Such a course would compel us to devote to more important matters than 
the affections of the skin, a much smaller proportion of space than the} r 
require and deserve. We shall therefore select only those cutaneous dis- 
eases occurring in early life, which are most important either from their 
frequency, or because thejr present in children some particular aspects or 
peculiarities, which make it necessary that they should be studied sepa- 



790 ERYTHEMA. 

rately from the same maladies in adults. Moreover, we shall treat of 
each one as it comes before us with greater or less copiousness of detail, 
according to its respective consequence to the medical practitioner, 
eschewing carefully any useless detail in regard to the more unimportant 
kinds, but endeavoring anxiously to describe with accuracy the history, 
diagnosis, and treatment, of such as demand a greater degree of con- 
sideration. 



CHAPTER I. 



RASHES. 



AETICLE I. 



ERYTHEMA. 



Definition; Frequency; Forms. — Erythema is a non-contagious ex- 
antheme, characterized b}^ a slight and superficial redness of the skin, ap- 
pearing in patches of irregular form and uncertain extent. It may or 
may not be preceded b} T or attended with signs of constitutional disorder. 
It is quite a, frequent affection in some of its forms. 

We shall describe three forms of the disease, restricting ourselves, as 
we have already said that we should, to those which seem particularly 
important in infancy and childhood. These forms are Erythema Fugax, 
Erythema Intertrigo, and Erythema Nodosum. 

Erythema Fugax. — This form of eiythema occurs chiefly in the course 
of various acute internal inflammations, and especially those which occur 
during dentition. It may occur during high febrile reaction brought on 
by any cause, especially in children having an active cutaneous circula- 
tion. We have observed it several times in the local inflammations ac- 
companied with great disturbance of the circulation, and particularly in 
a case of severe catarrh occurring during dentition, and in attacks of 
severe simple angina. In these cases it appeared in the form of a bright 
red rash, resembling very much a mild scarlatinous eruption. It was 
seated upon the upper part of the front of the thorax, and upon the outer 
surfaces of the arms. The red flush disappeared readily under pressure, 
and flashed back the moment the pressure was removed. There was no 
swelling whatever attending it, and the color was never so bright as that 
of a severe scarlatina, nor so deep as that of erysipelas or roseola. It 
lasted only a few hours or half a day, and then disappeared without 
desquamation. 

The chief point of interest in regard to this form of erythema, as it has 
come under our notice, has been the diagnosis between it and scarlet 
fever. This is to be made out only by recollecting that it has made its 
appearance in the course of another disease, while the child is already 



ERYTHEMA INTERTRIGO. 791 

suffering under some kind of sickness, which is not generally the case 
with scarlatina; by the less scarlet tint of the eruption, its more superficial 
character, and more limited extent ; and lastly, by its short duration. 

Erythema Intertrigo. — This form of erythema was for a long time, 
and is still by some, known by the single name of intertrigo. It occurs 
on the portions of the bod\ T exposed to friction by the contact of opposite 
surfaces, and to irritation from the passage over, or retention upon them, 
of the urinary secretion or the fecal discharges. The most common seats 
of it are, therefore, in the folds of the skin about the neck, in the axillse, 
the groins, about the anus, in the cleft of the nates, and on the inside of 
the thighs. 

As it appears in the creases of the skin about the neck, or in the axillae, 
it may be a mere red blush lasting a few da} 7 s, and then disappearing; 
or, after presenting this appearance for a short time, the inflammation 
may become much more intense, and occasion an excoriated condition of 
the surfaces attended with the discharge of a serous or a sero-purulent 
fluid; or, lastly, the inflammation may run into veritable ulceration, giving 
rise to extensive and very painful ulcers occupying the depth of the crease, 
presenting abrupt and jagged edges, and discharging very considerable 
quantities of pus. In these latter forms of the eruption it must be re- 
garded as a true eczema, and, indeed, this form of erythema has been by 
some authorities transferred to the group of eczematous affections, under 
the name of eczema erythematosum. In one child, two months of age, 
of delicate constitution, and imperfectly supplied with food, we saw the 
last-described form of the disease occupying at the same time the groins, 
the axillae, and the folds of the neck. The attack lasted two weeks, and 
very nearly proved fatal from the violent suffering it caused. In another 
child, not quite a year old, who was teething, it presented these charac- 
ters in the neck, and axillae, while in the groins it was much less severe, 
the latter parts being merely excoriated. 

Infants attacked with severe diarrhoea, with dysentery, or entero-colitis, 
and especially with that form of entero-colitis which so generally accom- 
panies thrush, are very apt to have an erythema of the nates, genital 
parts, and the internal surfaces of the thighs. So common, indeed, is 
this occurrence that M. Valleix regards erythema of these parts as an 
almost constant accompaniment and even precursor of thrush. For our 
own part we have very often met with it in cases of diarrhoea in infants, 
even in those of very moderate severity, but we have never seen it precede 
the appearance of the intestinal disorder. 

This form of erythema begins as a simple redness of the skin about the 
anus, between the buttocks, about the genital parts, and over the inside 
of the upper parts of the thighs. In a mild case of diarrhoea, and in a 
child properly cleansed after each evacuation by stool or urine, it will go 
no further than this : but in a severe attack of inflammatoiy diarrhoea, 
attended with frequent acid stools, and in a case in which proper cleanli- 
ness is not attended to, the long-continued contact of the discharges and 
soiled napkins will often cause the erythema to assume very distressing 
features. The redness extends in such instances along the leg to the 



792 ERYTHEMA. 

feet ; small papules, more or less numerous, make their appearance npon 
the inflamed skin ; these are converted into pustules and then into ulcera- 
tions, and if the case goes on unchecked, the ulcerations become larger, 
run together, and present raw, deep red, and bleeding surfaces, some- 
times of considerable size. Yery often the ulcerations present a grayish 
plastic exudation upon their surfaces. "When these conditions present 
themselves, the case has passed into an exudative form, and is properly 
to be regarded as an eczema papulosum or pustulosum. After cicatriza- 
tion there remain at the points where the ulcerations had existed reddish 
and copper-colored spots, which do not disappear for a considerable length 
of time. This form of eiythema rarely ceases entirely until the diarrhoea 
which has occasioned it has itself been cured. 

Erythema Nodosum generally occurs in feeble and delicate children. 
We have never met with it under five years of age. It ma}' develop itself 
upon different parts of the body, but occurs in by far the greater part of 
the cases on the forepart of the legs, or over the anterior edge of the 
tibia. We have only twice seen it elsewhere, and then it was situated 
upon the outer surfaces of the arms and forearms. It is preceded usually 
for several days by general indisposition, b} T lassitude, thirst, loss of ap- 
petite, and some feverishness. It appears in the form of red spots of an 
oval shape, somewhat elevated in the centre, and which increase gradu- 
ally in size. After a short time these patches become decidecllv elevated 
above the surrounding surface, and in passing the hand over them they 
give the sensation of nodosities. They increase gradually in size so as 
to measure from a few lines to an inch or an inch and a half long, by half 
an inch or an inch broad, when the} r present the appearance of reddish 
tumors, somewhat painful to the touch, and having an obscure feeling of 
fluctuation, as though about to suppurate. This, however, they never do, 
but after a short time they diminish in size, their red color changes into 
a bluish or livid tint, they soften, and finally disappear entirely in about 
twelve or fifteen da} T s. We have met with five well-marked cases of this 
disease. Three occurred in girls between six and twelve 3 T ears of age, 
and two in bo}<s of the same age. They all appeared to depend on de- 
rangement of the digestive function, attended with a somewhat impover- 
ished state of the blood, and general debilit} 7 . 

Diagnosis. — The only disorders with which erythema could be con- 
founded are erysipelas, roseola, or scarlatina, and this could happen only 
in regard to the erythema fugax. From eiysipelas it may be distinguished 
by the superficial character of the eruption, the absence of swelling and 
of smarting and burning pain, and by the slighter severity and much 
shorter duration of the symptoms in eiythema. Another important fea- 
ture is the peculiar, abrupt, well-defined, and slightly elevated margin 
which marks the edge of the eiysipelatous rash, and which does not exist 
with the same distinctness in erythema. Lastly, the singular regularity 
observed 03- eiysipelas in its gradual extension from place to place, is 
altogether unlike the march of erythema, which shows itself suddenly, 
or in a few hours, over large surfaces, and after lasting some hours or 



PROGNOSIS — TREATMENT. 793 

a few days, disappears without having followed the erratic course of 
erysipelas. 

In roseola the peculiar deep rose-tint of the rash will serve to distin- 
guish between it and the lighter red tint of erythema. 

The mild character of the general symptoms, and the absence of throat- 
affection in erythema, will prevent any one who is careful from mistaking 
the disease for scarlatina. 

Erythema intertrigo cannot be mistaken for any other disease, and if 
the course and peculiar local characters of erythema nodosum be borne 
in mind, it also ma}* be easily recognized. The only thing with which 
the latter might be confounded is phlegmonous erysipelas, but if the 
mild character of the general s3 T mptoms in erythema nodosum, the dis- 
tinctly circumscribed form of the tumors, and the fact that the disease 
never terminates by suppuration, are recollected, there need be no diffi- 
culty in making the diagnosis. 

Prognosis. — Erythema is a very mild disorder in a large majority of 
the cases. The only conditions under which it proves serious are when 
the intertrigo attacks children laboring under chronic entero-colitis, or 
those affected with severe thrush connected with gastro-intestinal inflam- 
mation, when it cannot fail to increase the sufferings and danger of the 
patient ; or, when it implicates, as we have seen it do in two instances, 
extensive portions of the cutaneous surface, involving the folds of the ' 
neck, armpits, groins, and genital organs, and this, too, without any 
other signs of disorder of the digestive apparatus than those showing- 
functional derangement. In one of these cases the extent and depth of 
the ulcerations were so great, and the resulting suffering and constitu- 
tional distress so severe, as to have very nearly destroyed the life of the 
infant, who was but two months old at the time of the attack. 

Erythema nodosum would almost certainly excite some uneasiness in 
the mind of a practitioner unacquainted with its real nature and probable 
course, and not only so, but it would prove tedious and difficult of cure, 
unless treated in the proper way. When managed correctly, however, it 
almost always gets well without any difficulty. 

Treatment. — Erythema fugax requires no special treatment. The 
disorder which has occasioned it is the point to which our attention must 
be turned, and not the eruption, which is a mere consequence. 

Ordinary, mild cases of intertrigo require no other measures than at- 
tention to strict cleanliness. The irritated parts must be carefully w r ashed 
two or three times a day, and if the nates, genital parts, and thighs are 
concerned, the washing must be repeated after each evacuation of urine 
or stool. After this the parts should be dusted with fine starch, with the 
powder of chalk or lycopodium, or with calomel, which, in our hands, has 
answered best of all, or else be well anointed with some mild ointment, the 
best of which is, in our opinion, Goulard's cerate. The washing ought 
to be performed with a fine soft sponge and warm water. The sponge is 
far better than the cloth generally employed, because, with the former, 
the cleansing can be effected by pressure, whilst with the latter it is neces- 



794 ERYTHEMA. 

sary to use a kind of wiping or rubbing process, which cannot fail to irri- 
tate the inflamed and tender surfaces. 

When the surfaces have become excoriated or ulcerated, attention to 
cleanliness is as important as ever. The application of the drying powders 
generally employed by the public becomes, under these circumstances, 
insufficient, and often rather injurious, except, indeed, in cases in which 
the excoriation is very slight ; here the lycopoclium powder, or very fine 
starch or magnesia, will sometimes answer a good purpose. When the 
excoriation is severe, and when ulceration is present, we have never ob- 
tained any good effects from powdering ; on the contrary, it has often 
proved injurious, and is at least troublesome and annoying from the in- 
crusting of the powder about the ulcer. We prefer, therefore, very greatly, 
when ulceration is present, to dress the part with simple cerate, Goulard's 
cerate, Turner's cerate, or with ointment of oxide of zinc. The ointment 
should be applied on a fine rag greased on one side, the rag being doubled 
and interposed in such a way between the opposite surfaces of inflamma- 
tion, as to be accurately applied to the whole extent of the disease, and 
thus prevent all friction or even contact of the opposite sides. These 
compresses ought to be changed three or four times a day, and all the 
discharges gently but carefully washed off by pressure with the sponge 
between each change of dressing. 

Whilst this topical treatment is being carried out, constant attention 
must be paid to the state of the digestive function. It is scarcely neces- 
sary to apply this remark to cases occurring in the course of thrush or 
entero-colitis ; but there is another class of cases that we have met with, 
in which, though the intertrigo is severe and obstinate, lasting as much 
as two, three, or four weeks, the signs of gastro-intestinal disorder are so 
slight as to pass unnoticed unless carefully inquired into. Thus they may 
consist merely in the fact that the child has a few more stools per day 
than usual, or that the stools are more liquid than they should be, or that 
they exhibit marks of derangement of the digestive process \yj the ap- 
pearance in them of imperfectly digested curd of milk, or by their green 
color and sour smell. Whatever be the character of the derangement of 
this function, as shown by the general appearance of the child, its appe- 
tite, degree of thirst, or the appearances presented hj the stools, we 
should always endeavor to rectify the disorder, and if the attempt prove 
successful, we shall often see the intertrigo vanish at once, while before 
it had resisted all the means employed for its cure. 

Erythema nodosum occurs generally, as already stated, in feeble chil- 
dren, and is usually accompanied with constipation or unhealthy stools, 
and slight febrile reaction. The proper treatment is a laxative at the 
beginning of the attack, and again in the course of the disorder, if 
necessary ; rest in bed, or on a sofa, which is very important ; and, after 
the operation of the laxative, the administration of tonics, and the use 
of a light but strengthening diet. The best tonic, as a general rule, is 
quinia. If this is not liked, or if there be anything in the case to con- 
traindicate its employment, we ma}^ substitute the compound tincture of 
bark, in the dose of fifteen or twenty drops, three times a day. If the 



ERYSIPELAS — CAUSES. 795 

child is pale and anaemic, iron is the proper remedy. It should be 
given in connection with the tincture of bark, or with small doses of 
brandy, when the appetite is poor, and the strength and spirits of the 
child much below their natural level. 

Topical remedies are not necessary as a general rule. When, however, 
the local symptoms are severe, or there is much heat or pain in the tumors, 
they should be kept covered with compresses moistened with some kind 
of mucilage, or with lead water and laudanum. 



AKTICLE II. 



ERYSIPELAS. 



Definition ; Forms ; Frequency. — Erysipelas is a specific, acute, 
febrile, non-contagious exantheme, characterized by a deep red rash, at- 
tended with heat and swelling of the skin, sometimes with inflammation 
of the subjacent cellular tissue, and terminating generally in resolution, 
but sometimes in suppuration or gangrene. The disease is very variable 
as to its extent, and has the peculiarity of spreading from place to place, 
the part first attacked recovering, whilst the neighboring surface is be- 
coming affected. 

The disease, as it occurs in children over six months of age, presents 
the same characters as in adults, and requires therefore no particular 
attention in this work. In younger children, on the contrary, and es- 
pecially in the new-born infant, it is different in several particulars from 
that of older children or adults, and this we shall attempt to describe. 
The form which occurs in new-born infants, has been technically named 
erysipelas neonatorum. 

Erysipelas is a rare disease in private practice, particularly amongst 
families in easy circumstances. In lying-in and foundling hospitals, on 
the contrary, it is of frequent occurrence, and it is not uncommon in hos- 
pitals for children and in the children of the poor. We have ourselves 
met with but four cases of erysipelas in children under six months of age, 
whilst we have met seven in older children. 

Causes. — The erysipelas of young children almost always starts from 
some previously existing cutaneous inflammation, the most frequent seats 
of which are the umbilicus during the process of separation of the cord, 
the irritated folds of the skin existing in er} T thema intertrigo, the inflam- 
mation accompanying the vaccine disease, and that which exists in the 
eczematous and impetiginous eruptions of the scalp, ears, and face. In 
a large majority of the cases observed in new-born children, the disease 
begins upon the abdomen, and generally at the umbilicus. In those which 
occur in children at the breast, it may show itself at any of the points 
above mentioned. 

The disease occasionally follows vaccination. We have ourselves met 



796 ERYSIPELAS. 

with three instances, in two of which the erysipelas broke out about the 
eighth day ; and in the third on the tenth day. In none of these cases 
could there be any doubt as to the purity of the vaccine virus used. In 
two, the disease extended over the greater part of the cutaneous surface, 
lasting three weeks, but terminating favorably in both cases. In the third 
case, it extended over the whole of the vaccinated arm, then attacked 
the upper part of the trunk, the face, and the right arm, and terminated 
fatally in the second week. 

But, though erysipelas commonly starts from, and m&y at first view 
seem to be produced b}^ these different local irritations, it is impossible 
to suppose that they can be anything more than the exciting agencies or 
causes, which bring into action a disease of which the seeds already exist 
in the economy. We must, therefore, in order to understand the real 
mode of causation of erysipelas, seek for the conditions that give rise to 
this predisposition to the malad} r , without which the above-mentioned 
exciting causes would rest without effect. These conditions are either a 
general epidemic constitution of the air, affecting certain districts of coun- 
try, and acting more or less upon all classes of the cpminunhVv, but with 
especial force upon the destitute and miserable ; or else a local epidemic 
constitution, such as that often occasioned b} 7 the unfavorable hygienic 
conditions of hospitals, and particularly of lying-in and foundling hos- 
pitals, or that not unfrequentby determined by the same causes in the 
crowded and miserable habitations of the poorer classes of the inhabi- 
tants of large towns and cities. 

Symptoms. — Infantile erysipelas is not generally preceded by any con- 
stitutional symptoms. The appearance of the eruption is usually the first 
sign of the disease. As soon, however, as the eruption appears, or very 
soon after, the child is attacked with fever, marked by frequent pulse, 
heat and dryness of the skin, restlessness and insomnia, and thirst. In 
the form of the disease which occurs in very young infants and in hos- 
pitals, or amongst the lower classes of the population, the eruption almost 
always begins upon the abdomen, and very generally at the umbilicus, 
whence it extends to the rest of the trunk, to the genital parts, and some- 
times to the inferior extremities. Even under the circumstances just 
mentioned, however, the eruption sometimes commences upon the face 
or upon the limbs. In children over two weeks of age, and in those ob- 
served in private practice, the disease may begin upon any part of the 
surface. It very often commences in the neighborhood of a vaccine pock, 
in a patch of erythema intertrigo, whether this be seated on the neck or 
about the pelvis, or it may appear first upon the face, or upon one of the 
extremities, without any apparent exciting cause, and extend thence with 
greater or less rapidity to other parts of the body. 

The form of the disease which occurs in very young infants, and which 
is by far more frequent in lying-in and foundling hospitals than under 
any other circumstances, begins almost always, at least when of a severe 
type, on the abdomen. It attacks hearty as well as more delicate chil- 
dren, and is generally very rapid in its progress. The erysipelatous sur- 
face is at first of a bright red and shining appearance, but soon assumes 



SYMPTOMS. 797 

a purplish hue. and as this occurs, becomes exceedingly hard to the touch, 
and somewhat, though not very much swelled. As the case goes on, un- 
less resolution, which is a rare event, should take place, or death occur 
at an early period, the purple color deepens into livid, vesications occur, 
the cellular tissue is destroyed, and in many instances extensive gangrene 
takes place, so that the scrotum has been seen to " become black and 
slough away, leaving the testicles bare, and hanging loose by the cords." 
(Maunsell and Evanson.) In a case that occurred to one of ourselves in 
private practice, the disease began on the ninth day at the umbilicus, and 
involved the soft tissues of the anterior wall of the thorax and abdomen. 
The skin sloughed in several places, exposing the muscles ; and at one 
point, just below the epigastrium, perforation of the abdominal wall oc- 
curred. Death occurred on the fifteenth day of the disease. In this form 
of infantile erysipelas, examination after death almost always discloses 
severe and extensive peritoneal inflammation, a condition which cannot 
fail, of course, to add greatly to the danger of the disease. 

But infantile erysipelas does not always exhibit these violent characters, 
though whenever it occurs in infants under a } r ear old it must be regarded 
as a very dangerous affection. When it attacks children over two weeks 
or a month old, it usually starts, as has been stated, from the neighbor- 
hood of a vaccine pock, from the inflamed surfaces of intertrigo or those 
of eczematous or impetiginous eruptions, or it begins without evident 
cause, as in adults, on the face, or on some part of the extremities. It 
appears first in the shape of a bright red inflammation of the skin. After 
a short time the erysipelatous surface becomes tense, shining, very hot, 
slightly swelled, and painful to the touch. Pressure causes the color to 
disappear, but this rapidly returns when the pressure is removed. Coin- 
cident^ with the appearance of the cutaneous redness the child is seized 
with fever, restlessness and severe thirst. From the spot first attacked 
the disease extends rapidly to the neighboring surfaces, from the neck 
and arms to the head and trunk, and from the groins or genital parts to 
the rest of the trunk and to the inferior extremities. When it begins 
upon the face, it extends to the scalp, and may theuce travel over the 
whole surface, or it may remain limited, as it often does in adults, to 
the head alone. In one case that we saw, in an infant three weeks old, 
in which it began upon, the face, it extended gradually over the whole 
cutaneous surface, and yet the child recovered. In another, two months 
old, it began upon the bridge of the nose, and from thence extended over 
the whole head, but did not reach the trunk or limbs. In a third case a 
vaccinated arm was attacked with erysipelas on the eighth clay of the vac- 
cination. The disease extended clown to the fingers, and upwards to the 
shoulder. From the shoulder it spread gradually over the whole trunk, 
and down the whole length of both lower extremities. As it was subsiding 
on the feet, it appeared on the arm opposite the one first attacked, and 
then attacked the corresponding side of the head, where it ceased. The 
child finally recovered after an illness of three weeks. 

As the peculiar inflammation spreads to the neighboring surfaces, the 
parts first attacked lose their reel color and swelling, and undergo a pro- 



798 ERYSIPELAS. 

cess of desquamation. In some instances, the inflammation has caused 
suppuration of the subcutaneous cellular tissue, so that even when the 
greater part of the surface first attacked has ceased to present the pecu- 
liar characters of the erysipelatous inflammation, there remain behind 
abscesses of o-reater or less extent. Thus, in one of the cases that came 
under our own notice, when the eiysipelas had left the head and thorax, 
and was confiued to the pelvis and inferior extremities, there were two 
abscesses on the scalp, and one over the right pectoral muscle, whilst all 
the skin between the abscesses had regained its natural appearance, with 
the exception of the desquamative process, which was going on as usual. 
In another, but rarer set of cases, the inflammation sometimes returns to 
the parts over which it has already passed. 

The swelling which accompanies this disease, is usually of an cedema- 
tous nature, — the oedema being most marked in the hands and feet, and 
upon the face, whilst upon the trunk it is much less considerable. 

The general symptoms consist at first, as already stated, of those indi- 
cating a strong febrile reaction. If the case goes on favorably these 
symptoms continue until the disorder terminates. But when the disease 
is severe, and especially when it ends in vesication, in extensive destruc- 
tion of the cellular tissue, or in gangrene, the general sj'mptoms are much 
more violent, marking thereby the gravity of the attack. The face and 
lips become pale, and the tongue and mouth dry. The child is in a state 
of constant agitation at first, and expresses its uneasiness and suffering 
by incessant moaning or ciying, but after a time it becomes heav}- and 
drows} T from exhaustion. The pulse is very frequent and feeble ; diarrhoea 
and vomiting make their appearance, and the child dies at last in a state 
of profound debility ; or convulsions occur towards the last, and termi- 
nate the case as they so often do in the diseases of infancy and childhood. 

The duration of eiysipelas in children is extremely uncertain, and de- 
pends veiy much upon its form. In that which occurs in the new-born 
child, or within one or two weeks after birth, it sometimes proves fatal 
within seven days according to Canstatt (Handbuch der Med. Klinik, 2d 
ed., vol. ii, p. 264). M. Bouchut {Mai. des Enf. Nouv.-Nes, p. 532) gives 
as an approximation to the ordinaiy duration of infantile eiysipelas, be- 
tween four and five weeks, and states that this is also the result arrived 
at by M. Trousseau. In one of the cases alluded to by us, in which 
the disease extended over the whole cutaneous surface, the duration 
was four, while in another it was three weeks ; in the one in which the 
eruption was limited to the head, the duration was a week. In the seven 
remaining cases, the disease was limited to the nose and eyelids, or the 
face and scalp, and lasted from three to ten clays. 

Diagnosis. — The diagnosis is very eas}\ The peculiar shade of the 
red color, the presence of decided though moderate tumefaction of the 
affected part, the severity of the general symptoms, and the characteristic 
erratic mode of extension from surface to surface, all assist to render the 
diagnosis very clear to those who have a proper amount of medical 
knowledge. 

Prognosis — Eiysipelas is always a dangerous disease in young children. 



PROGNOSIS — TREATMENT. 799 

The precise degree of clanger in individual cases will depend chiefly on 
two circumstances: first, the age of the subject; and second, the hygienic 
conditions under which the disease occurs. It is exceedingly dangerous 
in new-born infants, so much so indeed that M. Bouchut declares that 
they all die (Joe. cit., p. 532). This is in all probability almost strictly 
true of the cases which occur in infants only a few days old, particularly 
when they take place in lying-in hospitals, or even in private practice, 
during the prevalence of an epidemic of puerperal fever. The disease is 
always very dangerous in hospitals, even in infants over two weeks old. 
Yet it would appear not to be so grave as represented by M. Bouchut, 
who thinks that very few indeed have been cured even at that age ; for, 
of thirty cases in infants between one day and a year old observed by 
Billard at the Foundling's Hospital of Paris, sixteen, or only one more 
than half, proved fatal. Schwebel reports 54 deaths in 86 cases (Meissner, 
Kinderkrankheiten, 3d ed., vol. i, p. 3t2). 

In private practice, eiysipelas as it occurs in children between two 
weeks and a few 3-ears old, is a dangerous malady, but yet is far from 
being so in the same degree as in the new-born infant, and in hospitals. 
We have already stated that we have seen four cases in young infants ; 
one nine days old, in whom the disease proved fatal in fifteen claj^s ; one 
three weeks old, in whom the disease lasted four weeks, and travelled over 
the whole cutaneous surface ; another ten weeks old, and in whom also it 
travelled over the greater part of the cutaneous surface ; and a fourth two 
months old, in whom it remained limited to the head. These three last 
recovered. Again, we have seen seven cases of erysipelas of the face or 
head in children between seven months and twelve years old, and these 
also ended favorably. It must be recollected, however, to account for 
these recoveries, that they all occurred in hearty children, and under the 
most favorable h} T gienic conditions met with in private practice. To con- 
clude, MM. Rilliet and Barthez report nine cases of erysipelas of the face 
in children, all of whom, with three exceptions, were over five years of 
age. Five of the nine cases were idiopathic ; in four the disease compli- 
cated other affections. All of the spontaneous and one of the complicated 
cases recovered. The two others, both of which occurred in subjects la- 
boring under measles attended with pneumonia, proved fatal. 

Treatment. — The treatment of erysipelas in new-born infants, espe- 
cially when the subjects of the disease are the inmates of a hospital, and 
when it occurs coincidently with a puerperal fever epidemic, is, as ma} r be 
learned from the almost certain fatality of the disorder, exceedingly 
hopeless. M. Trousseau (Barrier, Traite Prat, des Mai. de VEnfanee, 
t. ii, p. 560) has made trial unsuccessfully of emollients in eveiy form, of 
fomentations, lotions, baths, and of ointments containing sulphate of iron. 
"I have tried," he says, "surrounding the whole body and limbs, with 
blisters in the form of strips ; the eiysipelas has passed over the obstacle. 
I have applied without success blisters upon the surfaces already invaded 
\)y the inflammation. I have obtained no advantage from mercurial oint- 
ment or from baths containing corrosive sublimate." He even tried the 



800 ERYSIPELAS. 

application of the actual cautery in points where the disease was begin- 
ning, but without effect. So, too, with methodical compression. 

Underwood says, that " upon the complaint being first noticed in the 
British Lying-in Hospital, various means were made use of without suc- 
cess ; the progress of the inflammation has seemed, indeed, to be checked 
for a while by saturnine fomentations and poultices, applied on the very 
first appearance of the inflammation ; but it soon spread, and a gangrene 
presently came on ; or where matter has been formed, the tender infant 
has sunk under the discharge." He adds that he then proposed bark, to 
which, sometimes, a little confectio aromatica was added, and that from 
that period several cases recovered. After this, linen compresses, wrung 
out of camphorated spirit, were applied in the place of the saturnine solu- 
tion, and proved successful in several instances in checking the inflam- 
mation. " Nevertheless, the greater number of infants attacked with this 
disorder sink under its violence, and many of them in a very few cla3 T s." 
{Treat, on the Dis. of Children, Am. ed., by Dr. Bell, from the 9th Eng. 
ed., p. 103.) In a note to the above, Dr. M. Hall states that fomentations 
of extract of poppies diffused in warm water, and poultices consisting of 
the same fluid and crumbs of bread, proved beneficial in many instances. 
Dewees recommends the application of a blister, when the eiysipelas is 
so situated as to allow the whole surface of inflammation and a portion 
of the neighboring healthy surface to be covered by the plaster. When 
this cannot be done, he prefers the use of the strong mercurial ointment, 
which must be applied over the whole of the eruption, and partly upon 
the healthy skin, and renewed as often as the part becomes dry. 

It is ver}^ difficult amidst the variety of advice given by different writers, 
and especially when we reflect upon the great mortality of the disease 
under every kind of treatment, to determine which to select. For our 
own part, we should prefer the use of cooling emollient applications 
during the first part of the attack, whilst the skin is of a bright red color, 
hot, and shining. When the circulation becomes languid, and the color 
of the eruption is disposed to deepen from red to purple, we should sus- 
pend the use of the emollient applications, and employ instead the lotion 
of camphorated spirit recommended by Underwood; the camphorated 
tincture of soap, which we have known to be of great service in the eiy- 
sipelatous inflammations occurring in patients of broken-down constitu- 
tion, and which is to be applied three or four times a day by means of a 
soft sponge ; or lastly, we would make trial of Kentish's ointment, a 
remedy found of great service by the late Dr. Charles D. Meigs, in the 
erysipelas of children {North Amer. Med. and Surg. Journ., vol. vi, p. 17). 
This ointment he prepared by rendering basilicon ointment soft (not 
fluid) with spirits of turpentine. It is rubbed upon the inflamed part 
with the fingers, the anointing being » repeated often enough to keep the 
part always very thinly covered." The internal treatment should consist 
in attention to the state of the bowels, which are to be kept soluble by 
the mildest laxatives, without being purged, and in a resort to tonic and 
stimulating remedies upon the very first approach of sjmiptoins indicating 
exhaustion. The best remedies of this class are proper diet, wine whey, 



TREATMENT. 801 

small quantities of brandy, and bark in connection with minute doses of 
carbonate of ammonia. 

In addition to these, the tincture of the chloride of iron, whose re- 
markable and almost specific influence upon the course of eiysipelas in 
more advanced life is so well established, should be given in large doses, 
proportioned to the tender age of the patient. Thus we may give two 
or three drops every three hours to an infant of a month old, as in the 
following; formula: 



R.— Tr. Ferri Chloridi, . 
Acid. Acetic Dil., . 
Liq. Ammonias Acetat.. 
Syr. Simp., 
Aquas, 



. f^ss. 
. fgss. 

• fSJ- 

. fgss. 

ad f Jiij.— M. 



S. — A teaspoonful every three hours. 

"When the inflammation has gone on to the production of subcutaneous 
suppuration, it becomes still more important to sustain the forces of the 
constitution, by giving the infant a healthy and abundant breast of milk, 
and by the internal use of brandy in small quantities, of bark, or better 
still, of quinia in combination with small doses of carbonate of ammonia. 
At the same time the suppurating surfaces must be well fomented, and 
dressed with warm poultices, and when necessary, laid open by careful 
incisions, observing the precaution to cause as small a loss of blood as 
possible. If the case occur in a hospital, or in a child placed in unfavor- 
able hygienic conditions, let the following statement of M. Barrier be 
borne in mind. " However much the life of an infant be threatened by 
erysipelas, if we can but persuade a wet-nurse to take charge of it, the 
pure air of the country is often seen to replace most advantageously all 
other therapeutical resources " (Joe. cit., t. iii, p. 562). 

As the preceding remarks have been restricted to the form of the dis- 
ease which occurs in infants under two weeks of age, we have now to 
make some observations on the cases which occur in older children. 

The disease is still, even at this latter age, a very dangerous one, though 
much less so, certainly, than in the new-born child. We have been de- 
terred from the use of depletion in any form by two reasons — the fear of 
exhaustion, which is so apt to occur in the disease, and the apprehension 
lest the leech-bites or cup-marks, in the case of local depletion, might 
prove new foci of the erysipelatous inflammation. The only internal 
remedies necessary in the beginning, are such laxatives as may be re- 
quired to keep the bowels soluble when they are bound, such as shall 
correct acidity or diarrhoea when either is present, and those which pro- 
mote an open state of the skin, and a free discharge of the urinary secre- 
tion. For the latter purpose we know none better than the solution of 
the acetate of ammonia, and the sweet spirit of nitre, about twenty or 
thirty drops of the former, with five of the latter, in sweetened water, to 
be repeated every two or three hours. The tincture of the chloride of 
iron should also be given, in the combination before recommended, in 
large doses, as three to six drops, every three hours, at the age of one or 

51 



802 ERYSIPELAS. 

two years. Should the attack be attended by any symptoms of prostra- 
tion, or at a later period of the disease, when the child begins to ema- 
ciate and grow feeble, its strength must be carefully supported by the 
use of proper diet, and of stimulants and tonics. The only proper diet 
for nursing children is, of course, breast-milk: for those who have been 
weaned, the diet should consist of preparations of milk, light animal 
broths, or beef-tea. The best stimulants are five or ten drops of brandy, 
five drops of aromatic spirit of hartshorn, or a quarter or sixth of a grain 
of carbonate of ammonia, in weak syrup of ginger, to be administered 
four or five times a da} r , or more frequently, when the forces of the child 
are greatly prostrated. The proper tonic is from a quarter to half a grain 
of extract of bark, or half a grain of quinia, in some suitable vehicle, 
every three or four hours. 

The best local treatment is, in our opinion, cooling or tepid emollient 
applications, as slippery elm bark, marsh-mallow, or flaxseed-tea, during 
the first few da} T s, whilst the reaction is marked, and the calorification of 
the bocly high. Somewhat later, when the strength begins to be reduced, 
and the color of the eruption to deepen, we should make use either of 
mercurial ointment, which is highly recommended by some, or of the 
Kentish's ointment, or camphorated tincture of soap, to which atten- 
tion has already been called. We would here propose the trial of an oint- 
ment which we have found not only soothing and comforting to the child, 
but also of manifest curative efficacy in the violent cutaneous inflamma- 
tion of scarlatina. It consists of one ounce of fresh cold cream, rubbed 
up with a drachm of glycerine. It should be smeared over the inflamed 
surface several times a cla}^, and need not interfere with the use of emol- 
lient applications. In scarlatina it has been most useful in reducing the 
burning heat of the eruption, and in softening the harsh and distended 
skin, and by these effects has aided greatly in moderating the severity of 
the general, and especially of the nervous s3 T mptoms. 

In children over two or three years of age, erysipelas must be treated 
on the same principles as in adults, by light but nourishing diet, and rest 
in bed, by the internal use of laxatives occasionally, of full doses of the 
tincture of chloride of iron, and of febrifuges, and by the external appli- 
cation of emollient infusions, so long as the sj'mptoms remain acute and 
the strength unreduced. But when, after a time, the fever begins to sub- 
side, or the child begins to show signs of debility and a tendency towards 
the typhoid condition, we must endeavor to maintain the life-actions in 
a proper degree of energy by a more nourishing and abundant diet, by 
the prudent administration of bark or quinia, and even by the use of 
brandy and ammonia, should the strength of the patient be disposed to 
give way suddenly or rapidly. Under these circumstances, moreover, 
the best local application will be either the Kentish's ointment, or the 
camphorated tincture of soap. 



ROSEOLA — CAUSES — SYMPTOMS. 803 



AKTICLE III. 



ROSEOLA. 



Definition; Synonymes; Frequency; Forms. — Roseola is a non-con- 
tagious, fugacious exantheme, characterized by rose-colored patches, of 
irregular size and shape, which are unaccompanied by elevations or 
papules, and the appearance of which is preceded and accompanied by 
febrile symptoms. 

It is often called in this country scarlet rash, and under that title sup- 
posed to constitute a very mild form of scarlatina. It is sometimes called 
also French measles, and rubeola sine catarrho. 

Roseola is of rather frequent occurrence amongst children, though 
more rare than either measles or scarlet fever. 

There are three forms of the disease met with in children, roseola 
aestiva, roseola autumnalis, and roseola annulata. As the two former, 
however, present no differences of any importance, we shall describe 
them under one head, whilst the latter, quite unlike the other two, re- 
quires that we should describe it apart. 

Causes. — Roseola may occur at all ages of infancy and childhood, and 
at any season, but is most common in summer and autumn. It has been 
known to prevail as an epidemic, but has never been thought contagious. 
It ma} T attack the same individual on several different occasions, one 
attack not preserving from repetitions. The variolous eruptions are 
sometimes preceded by roseola, and in some children it makes its ap- 
pearance on the ninth or tenth clay of the vaccine disease. Of the various 
causes that we have known to produce it, the' most frequent is certainly 
derangement of the digestive function during the first dentition. It is 
said also to be occasioned by sudden changes of temperature, by violent 
exercise, and by the use of cold drinks while the body is heated and moist 
with perspiration ; causes which strongly indicate that the nervous sys- 
tem is closely connected with its production. 

Symptoms. — Young children who have been suffering for a few days 
with disorder of the digestive function, often exhibit a slight roseolous 
eruption, lasting twenty-four or thirty-six hours, and then disappearing. 
The eruption in this mild form of the disease appears suddenly, often in 
the course of a single night, covering the trunk or even the whole surface 
with numerous patches, nearly circular in shape, or in irregular, broad, 
and waving lines, situated close together and yet distinct, and of a light 
rose color. In another, and rather more violent form, occurring espe- 
cially during dentition, the eruption appears after vomiting, fever, diar- 
rhoea, and slight nervous symptoms, or possibly after slight convulsions, 
with the characters above mentioned, except that the rash is deeper in 
color, greater in extent, and that it lasts generally a longer time — two, 
three, or four daj r s. Again, in a yet more marked form, the roseola 
sestiva and autumnalis, the disease is preceded by certain symptoms 



804 ROSEOLA. 

which it is important to note. It begins with more or less chilliness, 
alternating with heat, with loss of strength and spirits, with headache, 
restlessness, sometimes mild delirium, and even, it is said, though we have 
never seen them, with slight convulsive phenomena. At the same time 
there is some febrile reaction, marked by accelerated pulse, heat and dry- 
ness of the skin, thirst and loss of appetite ; the digestive function is shown 
to be deranged by the presence either of constipation or diarrhoea. After 
these symptoms have continued for two, three, four, or even six or seven 
days, the eruption appears first upon the face and neck, whence it ex- 
tends in twenty-four or forty-eight hours to the rest of the body. The 
rash resembles very closely, in some cases exactly, that of measles. It 
is in the form of irregularly circular and rather large patches, at first of 
a red, but soon changing to a deep rose color, and separated from each 
other by portions of healthy skin. The eruption is sometimes accom- 
panied by itching, and sometimes by stinging pain, and the febrile symp- 
toms generally continue, though moderated in degree, after the appear- 
ance of the rash; while in other instances the fever disappears entirely 
from that moment. The rash lasts between one, and two or three days, 
as a general rule, and fades away gradually until it has entirely disap- 
peared. In some cases it comes and goes alternately for a week after its 
first appearance. 

Roseola Annulata is a curious and interesting form of the disorder, 
from the singular and beautiful appearance of the bright rose-colored 
rings which constitute the eruption. We have seen but three examples 
of this variety, while we have met with a large number of cases of the 
other forms. It must, however, be of very rare occurrence, since MM. 
Guersant and Blache state that they have never chanced to meet with it, 
though they have seen a large number of roseolous eruptions (Diet, de 
Med., t. xxvii, p. 626). 

This variety of roseola appears in the form of rosy rings, or circles, 
whose centres retain the natural color of the skin. The favorite seats of 
the eruption are the abdomen, loins, buttocks, or thighs, or it may cover 
the greater part of the body. In one case that we saw, the eruption 
covered the face, neck, and trunk. In the other it was seated upon the 
face, trunk, and upper extremities. The rings are at first not more than 
one or two lines in diameter, but the} r enlarge gradually until their centres 
measure as much as half an inch in diameter. In some instances two or 
three rings surround one another, the skin in the intervals between them 
still retaining, however, its natural appearance. The disease is, when 
accompanied by symptoms of reaction, usually of short duration. The 
cases which occurred to ourselves lasted only three days, and were accom- 
panied by decided febrile symptoms, together with signs of digestive de- 
rangement. It sometimes assumes a chronic form, the eruption fading 
in color in the morning, and increasing again and causing heat of skin, 
in the evening. 

Diagnosis. — Roseola sestiva might be readily mistaken by a careless 
observer for measles or scarlatina, and especially for the former. We 
have no doubt whatever that cases of roseola are often regarded, under 



DIAGNOSIS — PROGNOSIS. 805 

the title of scarlet rash, as examples of a very mild form of scarlatina, a 
misapprehension which will explain some at least of the supposed in- 
stances of second attacks of scarlet fever in the same individual. This 
is a mistake, however, that ought not to occur, and need not, if the fol- 
lowing characters of the two diseases are property understood; The rash 
in scarlatina is, in the first place, of a much brighter tint, and it is more 
persistent and more uniformly spread over the surface than in roseola. 
When we come to analyze the characters of the two eruptions, there are 
other distinctions between them which assist greatly in making the diag- 
nosis. In scarlatina, the eruption is composed of very large patches, or 
it is absolutely uniform, and eventy distributed over large surfaces, as 
over the whole trunk, or over the flexor or extensor aspects of the limbs. 
It is seen to be composed, too, when minutely examined, of an aggrega- 
tion of very minute red points, which are dotted so closely together, as 
to present the appearance of a general scarlet blush. In roseola, on the 
contrary, the rash is composed of irregularly circular, crescentic, or waving 
patches, with portions of skin between of a natural or nearly natural color. 
The patches, moreover, are of different tint from that of scarlatina, being 
of a deep rose, instead of a bright red or scarlet color, and they cannot, 
upon close examination, be resolved into the minute dotted points which 
make up the scarlatinous eruption. When we add to these circumstances 
the facts, that in roseola there is no faucial inflammation, that the pulse 
has not the same frequency almost invariably present even in very slight 
cases of scarlet fever, that all the general symptoms are much less strongly 
marked, that no desquamation takes place in roseola, and that the dura- 
tion of the attack is much shorter, we think we have points of difference 
between the two, quite numerous and marked enough, to render the dif- 
ferential diagnosis easy to a careful observer. 

It has always seemed to us impossible to distinguish with certainty be- 
tween roseola and measles by the eruption alone, and we find that MM. 
Rilliet and Barthez are also of this opinion {Mai. des Enfants, t. i, p. 
132). We are told by writers that in roseola the patches composing the 
eruption are more distinct, larger, paler, and more irregular in shape than 
in measles, and that they are separated by intervals of healthy skin ; but 
we are quite satisfied that in some cases witnessed by ourselves, these 
differences were not sufficient to distinguish them. The diagnosis is to be 
made by attention to the following points : by the absence of catarrhal 
symptoms in roseola, by the slighter severity of all the general symptoms, 
and by the much shorter duration and greater irregularity of the initial 
phenomena, which latter seldom last in roseola more than one or two clays, 
and consist of symptoms of gastro-intestinal derangement, whilst in 
measles they last three and almost always four full days, and consist of 
very strongly marked catarrhal or respiratory symptoms, with very slight 
signs of gastro-intestinal derangement. 

Roseola annulata is so peculiar and characteristic in all its appearances 
as to prevent its -being mistaken for any other disease that we are ac- 
quainted with. 

Prognosis. — Roseola is probably never dangerous to life. If it ever 



806 URTICARIA. 

seems to be so, it must be in consequence of its occurring in connection 
with severe internal disease. 

Treatment. — The only treatment necessary in roseola is attention to 
diet ; the correction by that means, or, if necessaiy, by a mild laxative, 
by some antacid preparation, or by a mercurial dose, of the gastric or 
intestinal disorder; rest in bed, or seclusion in a chamber with a properly 
regulated temperature ; and the use of mild diaphoretics and of cooling 
demulcent drinks. 



ARTICLE IV. 



URTICARIA. 



Definition; Synonymes; Frequency; Forms. — Urticaria is a non- 
contagious exantheme, characterized by hard elevations upon the skin, of 
uncertain size and shape, and of a reddish or whitish color, or, more fre- 
quently, partly red and partly white ; the eruption is generally of short 
duration, is almost always accompanied with intense heat, and violent 
itching and burning, and is preceded by more or less marked signs of 
gastro-intestinal disorder. 

Its most common title is that of nettle-rash. The mild, discrete form 
of the disease is generally called hives, in the nursery. It is sometimes 
described under the name of essera. It is of very frequent occurrence 
amongst children in a mild shape. TTe have seldom seen in early life the 
abundant and severe eruption covering the greater part of the surface, 
which is met with in adults. 

The most common form of urticaria in adults is well known to be the 
urticaria febrilis, which is an acute disease of short duration. Two other 
forms of the disease, the urticaria evanida and tuberosa, are occasionally 
met with in adults, though they are both rare. In children, by far the 
most frequent form of the disease that we have seen is one in which there 
is scarcely any fever whatever, and in which the eruption is moderate ; 
the urticaria febrilis is, however, not at all uncommon in early life, while 
on the other hand, we have never met with an instance either of urticaria 
evanida or tuberosa at the age referred to. 

Causes. — Children possessing a fine and delicate skin, especially when 
they are at the same time endowed with a highly nervous temperament, 
are particularly predisposed to attacks of urticaria. The only other causes 
that we are acquainted with are the functional disorders of the digestive 
apparatus which occur in the spring and summer seasons, the influence 
of dentition, derangement of the gastric functions from the use of im- 
proper food, and lastly, the ingestion of certain articles of diet, which 
have been proven by long experience to be apt to occasion attacks of the 
disease. Of the articles last referred to, those which most frequently pro- 
duce this effect are crabs, the eggs of certain kinds of fish, certain cray- 
fish, and some kinds of smoked, dried, or salted fish. 



SYMPTOMS. 807 

Some children are exceedingly liable to the appearance upon different 
parts of the body of a few patches of urticaria. Yery slight disturbances 
of the gastric functions, a very warm day, and excessive clothing, will 
occasion in such subjects an attack of the disorder ; whilst in many others 
again, the disease is never seen mider any circumstances, or only at rare 
and long intervals. 

Symptoms. — The form of the disorder most commonly met with in chil- 
dren, in which there is neither fever nor other marked signs of disorder 
of the general health, is the disease generally described under the title of 
lichen urticatus, but which ought, it seems to us, to be considered as one 
of the varieties of urticaria. This eruption consists of large inflamed 
papules, which are irregular in shape, being either rounded or oblong, 
projecting most in the centre, and which appear suddenly, without any or 
only slight prodromic symptoms. The papules are of aJbright red color, 
excepting in their projecting central portions, where they are whitish or 
of a very pale red tint. The eruption is accompanied with a smarting 
and burning pain, and with the most violent and annoying itching, which 
the child endeavors to allay by frequent and often rude scratching. It is 
very fugacious in its character, appearing suddenly, lasting for a few hours 
or several days, and then disappearing entirely, or recurring again after 
a short time in the same or in new places. It terminates finally, after 
from a few days to several weeks, by resolution or by a slight furfuraceous 
desquamation. The most common seats of the eruption in children are 
the face, about the buttocks, or upon the thighs, or upper part of the arms. 

This is the form of the disease we have met with in infants, and in 
children under two and three j T ears of age. It is, as already stated,. of 
very slight consequence, being merely annoying and never dangerous. In 
} r oung infants it occasions sometimes much crying and irritability, which 
can be explained only by the discovery of the eruption. 

The urticaria febrilis is usually, but not always, preceded for a few 
hours or two or three clays, by feverishness, and by more or less marked 
signs of gastric disorder, such as nausea, chilliness, headache, and lan- 
guor. In other instances the fever and the rash occur at the same time. 
The eruption begins with a sense of itching, and with heat and burning 
of the skin, and soon after there appear on the shoulders, loins, inside of 
the arms, and about the thighs and knees, reddish and solid elevations, 
irregular in outline, but generally roundish or oblong. The latter shape 
is the one the elevations most frequently assume, and it is from the re- 
semblance which they bear in this form to the marks left by the stripes 
from a rod or whip-lash, that they are often called weals. The elevations 
project a good deal above the surrounding surface, forming knots or 
ridges ; their size is variable ; they have hardened edges ; they are reddish 
in color, except over the central and most projecting part, which is gen- 
erally, and always when the swelling is considerable, whitish in its tint ; 
and they are surrounded by a narrow areola of a bright red or scarlet 
color. The amount of the eruption is very uncertain, the elevations 
being sometimes separated by considerable intervals of healthy skin, 
while in severe cases, they are extremely numerous, and from their con- 



808 URTICARIA. 

fluent character in such attacks, give to the part upon which they are 
seated, a nearly uniform red color, and occasion at the same time a very 
decided puffing and swelling of the skin. 

The eruption, when at all considerable in degree, is attended with violent 
itching and burning. The former is often so severe and troublesome as to 
occasion the most distressing irritation to the patient, precluding all com- 
fort or quiet. It is increased by heat, and especially by that of the bed. 
The patches of eruption which appear first do not continue throughout 
the disease, but, after lasting from a few minutes to a few hours, fade 
away, and are replaced by new and successive crops. During the attack 
the patient is usually more or less feverish, and he suffers from languor, 
loss of appetite, furred tongue, and the usual signs of gastric derangement. 
The symptoms subside gradually, so that after a period varying from two 
or three da} T s to a week, the disorder has entirely disappeared, leaving 
behind no traces, except in a few instances a slight desquamation. 

"When this form of urticaria follows the ingestion of certain articles of 
food, the eruption usually appears within a very few hours after the meal, 
being preceded and accompanied by nausea or vomiting, pain and dis- 
tress in the epigastric region, giddiness, headache, and feverishness. 

Diagnosis. — There can be no difficulty in recognizing a case of urti- 
caria. The peculiar characters of the eruption, and especially the size, 
shape, and color of the solid elevations of which the patches consist, the 
violent itching and burning which accompany it, and its fugacious char- 
acter, render it unlike any other cutaneous disease, and ought to prevent 
an}' mistake as to its nature. 

Prognosis. — Urticaria is probably never dangerous in children. If it 
be accompanied by symptoms of a threatening or alarming character, 
these are dependent rather upon the gastric disorder, which is the cause 
of the urticaria, than upon the latter affection itself. We have never 
known it to be more than troublesome and annoying. 

Treatment. — There are but two really important indications for the 
treatment of this disease: to attend to the state of the digestive function, 
and to alla} T , by proper means, the distressing irritation occasioned by 
the itching and burning of the eruption. 

In the mild form of urticaria, called in the nursery " hives," and in 
scientific language, lichen urticatus, the only treatment necessary is care- 
ful regulation of the diet, and the use of means proper to correct any 
evident derangement of the digestive function. The food should be light 
and digestible, but at the same time nourishing. Milk, bread, light meats, 
and the plainest vegetables, form the proper diet for children over three 
years of age. Under that age, milk preparations, bread, and in those over 
a year old, light broths, ought to constitute the diet. In a large majority 
of such cases, no drug whatever ought to be given. The only ones likely 
ever to be required are occasional mild laxatives or gentle mercurials, 
when constipation is present, and some of the antacids, as very small 
quantities of magnesia or carbonate of soda, or lime-water and milk, when 
the stomach is acid. To allay the itching and consequent restlessness of 
the child, the patches of eruption should be well and frequently dusted 



ECZEMATOUS AFFECTIONS. 809 

with toasted rye or wheat flour, which are often very successful. Wash- 
ing the eruption with salt and water, when the cuticle is not broken, is 
sometimes very soothing, and when the patches are of small extent this 
may be clone without an}' impropriety. Dr. Watson speaks well of a 
lotion ("first recommended b} T Wilkinson"), composed of a drachm of 
carbonate of ammonia, a drachm of acetate of lead, and eight ounces of 
rose-water. 

In the urticaria febrilis the treatment must depend upon the cause of 
the attack. When it follows upon the eating of some unwholesome food, 
we must rid the stomach of the offending substance b}' an emetic, unless 
nature has already caused its rejection by spontaneous vomiting. When 
this end has been gained it will be proper to give some kind of cathartic 
medicine, and the best is castor-oil, as the mildest and most certain, in 
order to insure the discharge of the whole of the aliment which has been 
causing the mischief; or small doses of blue pill ; or hydrargyrum cum 
creta, with rhubarb, where there is present any signs of hepatic derange- 
ment. After this the only treatment necessary will be the use of cooling 
and demulcent drinks, containing perhaps a little sweet spirit of nitre, 
rest in bed, or at least seclusion in the house, for a few days, and careful 
regulation of the diet. The latter ought to be very light during the con- 
tinuance of the eruption, consisting merely of milk and bread, or of some 
kind of gruel or plain broth ; after the cessation of the disease, it should 
be augmented only with due care and quite gradually. To allay the itch- 
ing and burning of the eruption, and the general distress of the child, 
the best remedy is a warm bath carefully administered. This maybe 
repeated in six or eight hours if necessary, and between whiles the sur- 
face should be dusted with rye or wheat flour, as above recommended. 



CHAPTER II. 

VESICLES. 

ARTICLE I. 

ECZEMATOUS AFFECTIONS. 

As already stated in our introductory remarks on skin diseases, the 
idea of eczema is no longer restricted to a disease characterized by the 
formation of vesicles, but embraces all the numerous affections which 
present redness of the skin, frequently punctated; itching, infiltration, 
and exudation on the surface, with the formation of crusts. So far, in- 
deed, from vesicles being characteristic of it, it may be said, and espe- 
cially in regard to eczema in children, that its rarest form is that which 
is attended solely with their formation. The elementaiy lesions which 
may be present at the beginning of the attack, are either erythema, 
papules, vesicles, or pustules, and the disease is divided accordingly into 



810 ECZEMATOUS AFFECTIONS. 

eczema eiythematosnm; eczema papillosum, which embraces eczema liche- 
noides, and eczema prurigosum ; eczema vesiculosum, the typical eczema 
of Willan, one of the rarest of all its varieties ; eczema pustnlosum, or 
impetiginoides, which includes impetigo ; and eczema squamosum, which 
is usually of the chronic form, and resembles, in many cases, psoriasis. 
It is indeed called psoriasis by Dr. Wilson, who gives the name " alphos " 
to that scaly disease, which is still, by most authorities, and especially 
by Hebra, designated as psoriasis. 

It not unfrequently happens, also, that the various elementaiy lesions 
enumerated above may be present at the same time on a patch of eczema- 
tous eruption, so that a case which has begun as eczema erythematosum, 
or vesiculosum, may present the development of papules or pustules, or 
thick scabs, and thus become converted into the pustular or squamous 
form. This tendency for the blending of several elementary lesions in the 
same eruption, and especially for the conversion of the eruption into the 
pustular form, is very markedly seen in cases of eczema of children. 

Eczema is also divided according to its course, duration, and stage, 
into acute and chronic. 

Eczema shows, moreover, an especial tendenc}^ to attack certain parts of 
the surface, and presents various peculiarities in the different localities : 
in children, it frequently occurs on the scalp and face, though it extends 
over the entire surface of the body far more frequently in them than in 
adults. 

The special forms of eczema which will be here described, are simple 
acute eczema ; eczema of the scalp, and of the face ; eczema pustulosum, 
or impetigo ; eczema papillosum ; and chronic eczema, or eczema squa- 
mosum. 

Causes. — The causes of these affections are, to say the least, very ob- 
scure in most cases. It is probable that some peculiarities of constitu- 
tion predispose to it, and particularly the lymphatic temperament, or the 
scrofulous or tubercular diathesis. Exposure to unhealthy trygienic con- 
ditions, as want of cleanliness, insufficient or improper food, and crowded 
or ill-ventilated habitations, also render the system more prone to the 
development of eczema. 

In those who are thus predisposed, any trifling irritation may prove 
sufficient to provoke the eruption. One of the most common and un- 
doubted of these is the influence of the process of teething, and the 
majorit} r of cases of eczema in children occur during either the first or 
the early part of the second dentition. In like manner the application 
of irritants of any kind to the skin, or the inflammatory action set up 
by vaccination, m&y serve as an exciting cause. It is remarkable, also, 
what slight irregularities in diet, or alterations in the quality of the 
mother's milk, will, under such circumstances, induce an attack. In- 
deed, the use of artificial food in infancy, by disordering the digestive 
function, and impairing nutrition, msiy be regarded as a frequent cause 
of the disease. 

Symptoms. — We have already alluded to the fact, that in the eczema of 
young children, as indeed is true, to a less degree, of the disease at all 



ECZEMA — SIMPLEX, PAPULOSUM AND IMPETIGINOIDES. 811 

ages, we constantly meet with the most varied forms of eruption in the 
same case ; and have the opportunity of watching the development of 
papules, vesicles or pustules, until a case which has begun as one of ery- 
thematous eczema, presents the characters of the papular, vesicular, and 
ultimately of the pustular form. The predominance of one or the other of 
these typical forms of eczema is determined by the temperament and gen- 
eral condition of the child, and the grade of inflammatory action present. 

Eczema simplex, or vesiculosum, may occur on any part of the body, 
but in children is most frequent on the face and arms. The eruption 
appears, without any precursory s3 r mptoms, as an eiythematous patch, 
which is red and itchy, and ma} T present slightly raised pimples, and being 
rubbed and scratched, soon presents the formation of numerous, closely 
aggregated, exceedingly minute vesicles, containing a transparent limpid 
serum. After a short time the contained fluid becomes turbid and then 
milky, and is either absorbed, while the vesicles shrivel up and disap- 
pear by a slight desquamation, or else the fluid escapes by the rupture of 
the vesicles, and little thin scales follow, which are detached before long 
from the surface beneath. The eruption is attended with more or less 
itching and smarting, but does not generally give rise to constitutional 
symptoms. The vesicles are generally renewed by successive crops ; so 
that though the case may terminate in from two to three weeks, it is apt 
to continue for two or more months; 

Eczema Papillosum. — In the same way as the above form of eczema is 
characterized by the formation of vesicles, there are other cases where 
the eruption principally consists of papules, associated with erythematous 
patches. These papules do not remain dry and without exudation, as in 
the typical forms of lichen and strophulus, but soon present a slight 
clear or turbid serous oozing, and thin scaly desquamation of the epithe- 
lium. At the same time there will usually be found, on other parts of the 
bodj', patches of more fully developed eczema. The papules in eczema 
infantile may either be firm, small, and conical, as in lichen agrius, or 
softer, and more broad and flat, as in some forms of strophulus. 

Eczema Pustulosum or Impetiginoides. — Under this head we will de- 
scribe the affection usually st}ded impetigo, and formerly classed among 
the pustular diseases of the skin, but which possesses peculiarities which 
have induced dermatologists to transfer it to the group of eczematous 
affections. 

It may be described as a form of eczema characterized by the produc- 
tion of psydracious sero-pustules, containing a thin purulent fluid, which 
either break and discharge, or dry up and form thin amber-colored or 
more thick yellowish-brown crusts. 

The eruption usually begins as a reddened patch, studded with slightly 
raised pimples. As the inflammation increases, the cuticle is often raised 
into more or less well-defined vesicles, or the surface becomes excoriated, 
and there is a discharge of turbid or whitistbyellow secretion ; the skin 
now becomes infiltrated, and numerous rather small pustules, containing 
a light-colored pus, form on the red swollen surface. Not un frequently 
there are vesicles on the same patch, surrounding its margin. These 



812 ECZEMATOUS AFFECTIONS. 

pustules are usually broken by scratching or by friction against the dress- 
ings, and their contents dry up, forming amber-colored or brownish 
crusts. Frequently, also, blood is mingled with the discharges, and the 
crusts become dark-colored, or at times positively black. 

The crusts separate in a few days, the time varying according to their 
firmness and thickness, and leave the surface reddened, but without any 
permanent scar. Frequently, however, the disease passes into a chronic 
form; the eruption retreats to certain seats, as the scalp, or the flexures 
of the joints, where the skin remains somewhat infiltrated, while the 
cuticle is rough, scaly, and constantly desquamates, either in the form of 
a fine furfuraceous exfoliation, or of scales of considerable size. 

There are in reality but two specific varieties of this form of eczema, 
impetigo figurata, and impetigo sparsa, so named from the manner in 
which the pustules forming the eruption are arranged. From the greater 
frequency and severhYv^ of the disease, however, as it appears upon the 
scalp in young children, it has become customary to describe it, when 
seated upon that part, under a different title. 

Eczema capitis is often met with in infants at the breast during the 
first dentition, and at later periods of childhood, in those who are scrofu- 
lous, or who are placed in unfavorable hygienic conditions. It may be 
confined to a small portion of the scalp, or it may cover the head, and 
extend to the face and neck ; or again, it may be limited entirely to the 
latter localities, when it constitutes eczema of the face. In both cases, 
the eruption is very apt to run into the pustular form, constituting the 
disease known as impetigo capitis. 

When mild in its features, it consists of an eruption of numerous small 
vesicles or sero-pustules, spread over certain portions of the scalp, to 
which it may remain limited ; or it may cover the face at the same time, 
or it may attack alone the forehead, temples, and perhaps portions of the 
cheeks. It is attended, under these circumstances, with very slight red- 
ness and heat of the integument. The sero-pustules discharge their fluid 
contents and form thin crusts, which gradually fall off, leaving slightly 
reddened or excoriated surfaces, which soon disappear, or are followed 
by fresh crops of eruption, destined to pass through the same changes as 
the preceding ones. 

In more severe cases the disease may be confined either to the scalp or 
face, or it may, as stated above, exist upon both simultaneously. The 
eruption presents different appearances in these two situations. 

When seated on the scalp, it is often called by the English milky-crust 
or milk-crust, crusta lactea, tinea lactea, and porrigo larvalis ; and by the 
French, croute de lait, and gourme. 

On the scalp, as already said, the eruption may be either partial or 
general. It may consist at first of disseminated minute vesicles, which 
break, and form thin, lamellated crusts, of a 3 r ellowish or brownish color; 
or of pustules, yellowish-white in color, and of small size, seated on an 
inflamed base. The surface affected is at first small, but the eruption 
gradually extends to surrounding parts. It is attended with great heat 
and itching ; and, as the disease advances, the scalp becomes very much 



SYMPTOMS OF ECZEMA CAPITIS. 813 

inflamed, red, tense, swollen and painful. The eruption is now more 
completely pustular, and as the pustules open or are torn by the uncon- 
trollable scratching, the}' discharge an abundant thin sero-pus, or even a 
thick and viscid fluid, which glues the hairs together, and hardens into 
uneven brownish-yellow crusts. If the scalp is not kept clean b}' constant 
washing or by emollient applications, the crusts increase rapidly in thick- 
ness by successive discharges of fluid from the pustular surface beneath, 
until at length the whole of the diseased part is covered with thick, heavy, 
rough, and adherent crusts, of a brownish or yellowish-white color, or at 
times of a positive black from the admixture of blood which oozes from 
the inflamed surface, torn by the nails of the little sufferer. 

When neglected, the crusts become more and more thick, and from the 
heat of the head and exposure to the air, they undergo partial decompo- 
sition, and exhale a fetid, sickening odor, of the most disgusting kind. 
Among the children of the poor and destitute, lice often form in abun- 
dance, and add to the repulsive character of the disease. At first, the 
crusts are somewhat soft and moist, from the percolation through them 
of the fluid exuded beneath; but as they become more abundant and 
thicker, their outer surface becomes dry and sometimes very friable. The 
secretion from the inflamed surfaces often makes its way under the crusted 
mass above, and, flowing down over the forehead and behind the ears, 
irritates the parts that were before healthy, and thus extends the disease. 

When the crusts are removed by any means, the surface of eruption is 
found to be red, shining, wet, and discharging an abundant purulent or 
sero-purulent fluid, which escapes from minute excoriated points, dotted 
thickly over the inflamed scalp. The scalp is at the same time tumefied, 
tender to the touch, and abscesses may form beneath it. The lymphatic 
glands, as the occipital, submental, or cervical, are frequently enlarged, 
and at times suppurate. 

When the disease has lasted a considerable length of time, it tends" to 
assume a chronic form. The inflammatory action extends to the hair 
follicles, and often occasions partial loss of hair over larger or smaller 
surfaces. This kind of alopecia is not, however, permanent. The hair 
bulbs are not destroyed, but merely inflamed, so that the hair grows 
again after the cure of the disease. The tissues of the scalp remain 

thickened, but the amount of the secretion diminishes ; and the painful 
irritation and itching are less troublesome. Under these circumstances, 
the crusts are less thick and massive ; they become lighter, thinner, and 
are more easily detached. The epidermis is dry, uneven, and rough, and 
there is a continual desquamation of fine furfuraceous particles, consti- 
tuting a form of pityriasis capitis, or of epithelial scales of various sizes, 
resembling a case of psoriasis. 

On the face {Eczema faciei), the disease usually shows itself first on 
the forehead and cheeks, to which parts it may remain limited, or whence 
it may extend to the lips, chin, ears, and neck. The nose and eyelids 
are seldom attacked, though we have occasionally seen the upper eyelids 
slightly affected. 



814 ECZEMATOUS AFFECTIONS. 

The disease begins by the appearance of minute vesicles or sero-pus- 
tules on a patch of reddened and slightly swollen skin; there is also 
excessive pruritus. When the eruption is scanty, and rather vesicular, 
and the degree of inflammation slight, the cuticle breaks, and there is a 
discharge of a thin, turbid, serous fluid, which dries into delicate scales, 
or thin lamellated crusts. 

When the accompanying inflammation is more severe, however, the 
eruption is more truly pustular, the pustules being numerous and rather 
large, and the discharge copious, so that when the formation of crusts is 
not interfered with by topical applications, or by the scratching of the 
child, large portions of the affected surface become covered with thick 
yellowish, brownish, or brownish-red crusts, which present the general 
appearance of a mass of incrustation, broken by cracks and fissures into 
portions of very irregular size and shape. 

In the milder cases, when the scales drop off, the skin may appear red- 
dened and moist, or ma} 7 seem to be covered with a very delicate, shining 
epidermis which is perfectly dry or presents tiny drops of serum or minute 
cracks. In the more severe cases, if the crusts are detached by any cause, 
the skin beneath appears red, swollen, inflamed, and wetted with a more 
or less abundant sero-purulent fluid, sometimes mixed with blood, that 
oozes from numerous small points on the excoriated and inflamed sur- 
face. The eruption is attended with severe itching and smarting, to re- 
lieve which the child often tears the affected surface with the nails, so as 
frequently to remove the crusts, wound the skin beneath, and cause more 
or less bleeding from the part. 

In this more severe form, when the discharge forms a thick discolored 
scab covering the scalp or face like a mask, the disease has received the 
names of porrigo or impetigo larvalis, which are less accurate than eczema 
larvale. It corresponds to the impetigo figurata, as met with in other 
parts of the body. 

When the eruption is more scant} 7 and developed in small groups on 
the scalp alone, the discharge is less copious, and soon concretes into 
dry, friable, brownish crusts of irregular shape, some of which are very 
adherent, matting together a larger or smaller number of hairs, while 
others are broken into small and dry fragments, which have been com- 
pared to particles of mortar dispersed among the hair. Many of the pus- 
tules in this variety are formed at the base of the hairs, so that these 
particles of crust, being pierced by the hairs, have somewhat the appear- 
ance of a string of rude beads. This form of the disease has been known 
as tinea, or impetigo, or porrigo, granulata; but for the sake of uniformity, 
it might be styled eczema granulatum. It corresponds to the impetigo 
sparsa, as met with on other parts of the body. 

Eczema larvale, whether confined to the scalp or face or existing on 
both parts at once, causes, when it exists in the acute form, much distress 
and annoyance to the child. The heat and tension of the part, and par- 
ticularly the itching, occasion much restlessness and irritability ; they 
make the child cross and peevish, disturb its sleep and sometimes cause 
slight febrile attacks, which debilitate and injure the health. Indeed, 



SYMPTOMS OF ECZEMA IMPETIGINOIDES. 815 

when the disease has lasted a considerable time, it often induces extreme 
anaemia and impairs severely the general nutrition of the child. In other 
cases, however, the general health remains perfect, — all the functions of 
the body going on well, notwithstanding the local distress and irritation. 
The lymphatic glands situated behind and in front of the ear, and those 
on the back and front of the neck often inflame, enlarge, are frequently 
hard and painful to the touch, and in a few instances suppurate, though 
the latter occurrence is not frequent. 

The duration of eczema larvale is very variable in different cases. 
Mild cases, and particular^ those in which the eruption is confined to a 
limited extent, often get well, or are readily cured in two or three months. 
When, on the contraiy, the disease is severe and extensive, the duration 
is much longer, seldom less, according to our experience, than several 
mouths or even one or two years. In most cases, however, the intensity 
of the disease varies from time to time, so that at one period it may seem 
to be subsiding rapidly, or it may even disappear almost, or be very 
greatly ameliorated, only to break out again with renewed violence under 
the influence of some exciting cause, as the cutting of new teeth, some 
change in the weather or season, or some alteration in the health of the 
child which cannot be explained. This affection is, as already stated, 
almost entirely confined to the age of dentition. The disease often begins 
some months before the appearance of the first teeth, and though it gen- 
erally ceases, or is cured before the termination of dentition, we have 
known it to run on unchecked three months after the conclusion of that 
process and then to be removed only by medical treatment. 

Eczema granulatum is comparatively a slight disorder, and is usually 
much more under the control of remedies and of much shorter duration. 

There is a local variety of eczema which requires a brief allusion. It 
is known as eczema tarsi and affects the edges of the eyelids, especially 
in strumous children in whom it is often associated with strumous oph- 
thalmia. It is attended with the formation of pustules at the openings 
of the hair follicles, itching, thickening of the eyelids from infiltration, the 
formation of crusts, and a tendency to adhesion of the edges of the lids 
together, especially in the morning after they have been in contact during 
sleep. If not cured by appropriate treatment it frequently leads to dis- 
tortion of the hairs, which assume abnormal directions in their growth, 
and to inversion or eversion of the lids. 

Eczema impetiginoicles also presents itself in other parts of the body 
under the same two forms of impetigo figurata and sparsa which have 
been described as occurring on the head. We have, indeed, more than 
once alluded to the tendency of eczema in children to develop itself in 
different parts of the surface, at times occupying almost the entire cutane- 
ous surface, and presenting all its varieties at one and the same time. 

Impetigo figurata, when seated on the trunk or limbs, usually pre- 
sents a large eruptive surface. On the arms we have seen it extend 
from the shoulders to the hands, and, as a general rule, it has been 
most severe on the outer portions of the limbs. On the trunk and lower 
extremities it has usually affected surfaces of much less considerable size, 



816 ECZEMATOUS AFFECTIONS. 

and has commonly appeared in a patch of an irregularly oval shape, and 
of four, five, or six inches in diameter. 

In these localities it presents much the same appearances as those al- 
ready described in the account of eczema capitis. 

Impetigo sparsa, which is the scattered form of the eruption, is quite a 
common affection in children of all ages. It differs from impetigo figu- 
rata in the arrangement of the pustules, which, instead of being confluent 
or grouped closely together, appear singly or in small clusters. It most 
frequently appears on the face and scalp, but is also met with on the ex- 
tremities, being not unfrequent in children, according to Wilson, on the 
hands and feet. 

The eruption appears as small yellow pustules, seated upon an inflamed 
base and attended with more or less itching. The patch frequently pre- 
sents a surrounding circle of confluent vesicles or phlyctense. The pus- 
tules soon break and discharge a sero-purulent fluid, which hardens into 
a rugous, more or less projecting, friable crust, seeming to consist of dif- 
ferent la3 r ers superimposed one upon the other. When the crusts fall, or 
after their removal by topical means, there remains beneath an inflamed 
surface, which may be either excoriated, giving issue to additional fluid 
and a renewal of the crusts, or dry, and disappearing little by little by 
the gradual fading away of the red color of the spots. 

JEczema Chronicum. — Eczema infantile, if left to itself, has no natural 
tendenc}^ to cure, but usually becomes chronic, as in the adult. 

When the disease passes into this form, no matter what ma} x have been 
the original type of the eczema, the eruption gradually assumes uniform 
and characteristic appearances. The various forms which have already 
been described are then to be regarded as varieties of acute eczema, 
while the chronic form is common to them all and represents the condi- 
tion into which all the acute A T arieties may merge. 

The skin in chronic eczema is either very much inflamed and thickened, 
presenting excoriations with deep cracks and fissures, which pour out an 
abundant ichorous secretion, or, more frequently, the inflammation is less 
severe, there being much less heat, redness, and infiltration of the skin, 
fewer excoriations and cracks, and a smaller amount of effusion. The 
affected surface is, in these cases, dry and parched, and constantly throws 
off a fine furfuraceous desquamation, as in phtyriasis, or scales of dried 
cuticle of various sizes, as in psoriasis. 

This form is most common on the scalp, behind the ears, about the 
neck and upper part of the trunk, and in the flexures of the joints. It 
usually lasts for months, and is difficult of cure. It is attended with 
severe itching, which is sometimes so troublesome as to occasion the most 
distressing and uncontrollable restlessness at night. 

Xot rarel} T also, on the application of any exciting cause, the eruption 
will spread from the spots where it has been lurking in the chronic form, 
and invade more or less of the surface, assuming all the appearances of 
acute eczema. 

Diagnosis. — It must be borne in mind, in making the diagnosis of 
eczema, that its characteristic sj-mptoms, which are present in varying 



PROGNOSIS. 817 

proportion in nearly every ease, are redness and infiltration of the skin, 
attended with marked itching ; exudation on the surface, with the forma- 
tion of crusts. 

Eczema simplex when seated on the hands and between the fingers, 
may be mistaken for scabies. The distinction can, however, be made 
by attention to the following points : the vesicles of eczema are flattened 
and aggregated ; in scabies they are acuminated, isolated, and entirely 
distinct. There will also be frequently found, in scabies, vesicles on the 
hips where the hand of the nurse from whom the child has caught the 
disease has been placed to support it. In scabies also the vesicles pre- 
sent little red lines, running off from their margins, and marking the 
course taken by the acarus ; and lastly, in that disease careful search will 
almost always enable us to detect the insect or its ova, which are infal- 
libly characteristic of the disease. 

From sudamina, with which eczema vesiculosum might perhaps be con- 
founded, the latter disease ma} T be distinguished by the facts that the 
vesicles constituting sudamina are much larger, that they are discrete and 
scattered, that they are associated nearly always with profuse perspira- 
tion, and that they are unaccompanied by an inflammatory state of the 
skin or by itching. 

Eczema impetiginoides, especially when affecting the scalp, might pos- 
sibly be mistaken for favus, from which, however, it may readily be distin- 
guished by the facts that, in the latter disease, the pustules are imbedded 
in the epidermis, and that the crusts present a peculiar bright yellow 
color, and are of an umbilicated or cup-like shape. 

Eavus is also followed by incurable alopecia and is contagious, and mi- 
croscopic examination will detect the peculiar fungus, the achorion, upon 
which it depends, in all of which circumstances it differs entirely from 
eczema. 

Prognosis. — Eczema infantile is rarely dangerous to life, though it 
sometimes occasions much distress to the health by the suffering, irrita- 
tion, and especially by the loss of sleep, which it entails. In one instance, 
however, that came under our observation, of very severe eczema larvale 
combined with extensive impetigo figurata, in a child a few months old, 
the disease ended fatally some weeks after the child had been put under 
the charge of a homoeopathic practitioner. 

In the prognosis given by the physician, especially in the instance of 
extensive eczema pustulosum, he should never forget to refer to its prob- 
ably long duration, and to its disposition to return even after an apparent 
cure has been effected. It often lasts, in this way, for many months, and 
sometimes one or two years or even longer. This difficulty of cure, and 
obstinate tendency to recur, are often owing to its dependence on some 
constitutional disturbance, or upon derangement of the digestive system. 
It ought, therefore, to be looked upon as the expression of a general dis- 
order ; and its cure will at times be found to depend upon the removal of 
the constitutional fault. 

It is on this account that the opinion has long been popularly enter- 
tained, that extensive eczema should not be treated by severe local reme- 

52 



818 ECZEMATOUS AFFECTIONS. 

dies, since, if suddenly arrested by such means, the disease might fall 
with all the greater severity upon parts more important to life. 

We no longer, however, attach an}' importance to this popular appre- 
hension, and always endeavor to secure as rapid a cure as possible, by 
appropriate general and local treatment. 

Treatment. — The remarks which have been already made in connec- 
tion with the causes and constitutional character of manj^ skin diseases, 
will readily suggest the indications which are to be followed in treatment. 
It is necessary to remove the constitutional disturbance which may be the 
essential cause of the affection, allay the local distress, and promote the 
healthy vigorous nutrition of the skin. These principles, which guide the 
practice of most dermatologists, are especially insisted on by Mr. Erasmus 
Wilson, who gives to elimination the first place; to alleviation of local 
distress the second, and to restoration of 'power the third. There are, 
however, some high authorities who regard the constitutional treatment 
in cases of eczema as of very secondary importance, and rely almost ex- 
clusively upon local measures. Our own observation has convinced us 
that the most rapid and certain cures can onlj T be effected by a judicious 
combination of general and local remedies, either of which, however, may, 
under special circumstances, assume peculiar and paramount importance. 

The general treatment of eczema must depend on the state of health 
of the patient at the time, on the extent and activity of the eruption, and 
on its acute or chronic character. 

In mild cases which show but little disposition to extend, and are not 
attended by much irritation, regulation of the child's diet, and the use of 
the most simple bland applications will be sufficient. 

When the disease is more extensive and attended with much irritation, 
it is necessary to examine carefully into the state of the digestive func- 
tion, and if this be in any way disordered, to endeavor to restore it to a 
more healthful condition. 

When the child is teething, the gums ought to be examined and, if 
found swelled or inflamed, the} T should be lanced as often as necessaiy. 
The diet must be properly regulated, the food being changed if that 
which has been previously taken is found not to be well and completely 
digested. 

Constipation, if it be present, must be overcome by altering the diet, 
or b}^ the administration of rhubarb, small doses of magnesia, Rochelle 
salts, or sulphur. Purgatives have been strongly recommended by some 
writers in the treatment of eczema pustulosum, but we should advise 
their use only when constipation is present, and in hearty, vigorous chil- 
dren. In most cases, the gentlest laxatives, given merely to regulate the 
bowels, are to be preferred. 

If there are evidences of acidity of the stomach, it is well to employ 
some of the various preparations of the alkalies. 

So also when diarrhoea is present, it should be treated hy attention to 
the diet ; and b}' the administration of a weak castor-oil emulsion, con- 
taining small quantities of laudanum, when the stools are feculent, but 
small, frequent, and attended with griping ; when they are thin and 



INTERNAL TREATMENT. 



819 



watery, greenish, and composed in part of mucus, the following prescrip- 
tion will often prove very useful : 



]&. — Tr. Krameria?, . 

Tr. Opii, .... 
Soda? Bicarb., . 
Syrup Zingib., . 
Aqua?, .... 
S. — A teaspoonful two or three times a day, fo 



. gtt. vi. 

. f^vij. 
. . fgij.-M. 

children of one or two years old. 



When the eruption has persisted for some time, and tends to become, 
or has actually become, chronic, resort must be had to remedies which 
are capable of modifying the constitutional condition of the child. In 
mam T such cases, the child shows evidences of impaired nutrition, and is 
weak and debilitated ; so that the remedies clearly indicated are those 
which will tend to invigorate the general health and aid in the restoration 
of power. 

The reined}" which extensive experience has led us to regard as the 
most useful in all such cases of chronic eczema is arsenic. The prepara- 
tion of arsenic which is best adapted for administration to children is 
Fowler's solution ; which we are in the habit of giving in combination 
with iron, as in the following formula: 



R- 



ttj? xvj ad xxxij. 



-Liq. Potassae Arsenitis, . 
Yin. Ferri. Amari, 

Syr. Tolutani, aa, f ^j. 

Aq. Carui, f ^ij. — M. 

Dose. — A teaspoonful thrice daily, directly after food, for an infant from six months 
to a year old. 

TTe have never known any serious inconvenience to follow the admin- 
istration of this remedy, the only annoying symptoms occasionally pro- 
duced being slight gastric irritation and diarrhoea, and a little puffiness 
of the eyelids. By giving it immediately after taking food and properly 
diluting it, it rarely causes any gastric irritation, and even should it do 
so, the symptoms rapidly disappear if the remedy be temporarily sus- 
pended, or given in a smaller dose or less frequently. The mother or 
attendant should, therefore, be carefully instructed to instautly suspend 
its administration upon the appearance of any disturbance of digestion. 
The puffiness of the eyelids, which is one of the earliest and most char- 
acteristic symptoms of the physiological action of arsenic, is of no alarm- 
ing import, and the remedy need not be instantly suspended on account 
of its appearance : though it is more prudent, at least, to reduce the dose 
and frequency of administration, and to watch carefully for the occur- 
rence of any further signs of the overaction cf the drug. 

The period of continuance of this treatment must depend upon the 
state of the eruption, and the manner in which the arsenic is tolerated ; if 
necessary, however, and if it causes no gastric irritation, it ma}" be con- 
tinued for many weeks or months. 

In cases which persist despite local treatment and the internal admin- 



820 ECZEMATOUS AFFECTIONS. 

istration of arsenic, we have frequently found the use of cod-liver oil fol- 
lowed by marked benefit. It may be given combined with the arsenic, 
or, if the stomach will not tolerate it in an undisguised form, in the form 
of an emulsion with arpmatics, as recommended at page 325. 

In cases attended with marked anaemia and debility of constitution, 
associated with a scrofulous tendency, we have obtained good results from 
the administration of the syrup of the iodide of iron. This may be given in 
combination with the compound syrup of sarsaparilla, in the dose of from 
o-tt. ij to gtt. v of the former, diffused in from a quarter to a half teaspoon- 
ful of the latter, three times a day, for children of one or two years of 
age. 

It is recommended by some authors to administer calomel in consider- 
able and frequently repeated doses in severe eczema. Mr. E. Wilson ad- 
vises 1 gr. of calomel rubbed down with 1 gr. of white sugar or sugar of 
milk, as the dose for the youngest infant ; for a child one year old, a grain 
and a half; for a child two years old, 2 grains ; this dose being repeated 
once a week or oftener, according to circumstances. We have not, how- 
ever, found any necessity for employing calomel as an element of our 
regular treatment, resorting to minute doses of it or of blue pill only when 
the stools are whitish or clay-colored and offensive ; under which circum- 
stances it has almost always been productive of good effects. 

The diet should be nutritious and strengthening, but, at the same time, 
light and of easy digestion. 

If the appetite is weak and capricious, tonic remedies, as tincture of 
bark, or quinia, in combination with the ferruginous preparation em- 
ployed, ought to be administered. 

In rare cases, where the patient is of full habit, of gross development, 
and of florid complexion, the diet must be somewhat restricted, and a 
moderate use of cathartic remedies, as small doses of saline laxatives, of 
blue pill and extract of taraxacum, or of sulphur, resorted to. 

Local Treatment. — In mild cases, when the patches of eruption are 
small, and with veiy little disposition to extend, and the degree of in- 
flammation is slight, a cure ma} r often be obtained with great ease by 
the application, twice or thrice a da}^, of an ointment composed of one 
part of ung. l^clrarg. nitratis to three or four parts of simple cerate, or 
lard ; of weak tar ointment ; or of the benzoated oxide of zinc ointment, 
as recommended below; or it maj r even be sufficient simply" to wash the 
eruptive patches with cool water several times a day, and to anoint them 
in the evening with ointment of cucumbers. 

When the disease is attended with much irritation, the application of 
compresses repeatedly wet with cold water, or with some emollient decoc- 
tion, as of marsh-mallow root, flaxseed, sassafras pith, or slippery-elm 
bark, or the use of warm bread and water poultices, are frequently of the 
greatest service in reducing the heat and irritation, and arresting the 
progress of the eruption. 

The compresses must be repeatedly wetted with the cool applications, 
to prevent the temperature of the liquid from being raised by the heat of 
the body. They may be retained upon the part for several hours at a time, 



LOCAL TREATMENT. 821 

or throughout the clay, as they may be fouud to suit the eruption, and 
during the night may be substituted by a dressing of benzoated oxide of 
zinc ointment. 

When warm, moist applications, as poultices, are employed, they should 
always be covered with oiled silk to prevent them from drying. 

The application which we have used with most marked and uniform 
advantage, and which we believe to be the one best adapted to the forms 
of acute eczema, is the benzoated oxide of zinc ointment, 1 applied in the 
manner directed by Mr. Erasmus Wilson. 

He directs ;i that the ointment should be applied abundantly, and 
gently distributed upon the surface until every part of the eruption has 
a complete coating ; the ointment should be applied night and morning, 
and if accidentally rubbed off, or used upon parts exposed to the air 
and friction, it may be repeated more frequently. When once applied, 
the ointment shoukl be considered as a permanent dressing to the in- 
flamed skin, and never removed until the skin is healed, unless special 
conditions arise which render such a process necessary." To secure the 
permanent contact with the skin, he recommends that pieces of linen 
rag, or a small garment of linen, be kept constantly upon the parts, 
covered with the ointment. 

In cases where the disease has lasted some time, and the discharge 
has dried, so as to form more or less thick and hard crusts, it is abso- 
lutely esseutial to get rid of these entirely before any of the applica- 
tions to be hereafter recommended can be efficiently applied. This is 
especially the case in eczema capitis, when masses of scabs have been 
allowed to collect and mat the hair together. The removal of these 
crusts is best effected b} T the use of thick, moist, and soft poultices, 
which, when applied to the head, should be inclosed in a fine linen rag, 
in order to prevent the matter of which the poultice may be composed 

i We quote from Mr. Wilson (Diseases of the Skin, 7th Amer. ed., 1868, p. 771), 
the precise directions for preparing this ointment: 

BeWs Formula. 

Unguentum Oxydi Zinci, Benzoatum. 

R. — Adipis preparati, ...... !|vj. 

Gummi Benzoini, Pulveris, .... ^j. 

Liquefac, cum leni calore, per horas viginti quatuor, in vaso clauso ; dein cola per 
linteum, et adde 

Oxydi Zinci, Purificati, 3jj. 

Misce bene, et per linteum exprime. 

If it be desired to make this ointment rather more stimulating, we may add a little 
alcohol, as in the following: 

Unguentum Oxydi Zinci, Benzoatum, cum Spiritu Yini. 
R. — Ung. Oxydi Zinci, Benzoati, .... ^ij. 

Spiritus Yini rectificati, f ^ij. 

Misce, ut fiat unguentum. 
Instead of spirits of wine, spirits of camphor, distilled glycerine, liquor plumbi 
diacetatis, Peruvian balsam, or the juniper tar ointment, may be combined with the 
benzoated ointment of oxide of zinc, in the same proportion as above, one drachm to 
the ounce. 



822 ECZEMATOUS AFFECTIONS. 

from adhering to the hairs. Over the outside of the poultice should 
always be placed an oil silk covering, to preserve it moist and soft. 
The poultice may be made of almost any unirritating material usually 
emplo3 T ed for such purposes. One of the best is that made of stale 
bread and water, with the addition of a little washed lard or hot almond- 
oil to keep it soft. The water is preferable to milk, as the latter often 
sours soon after being applied. Another excellent poultice is one made 
of ground slippery-elm bark, mixed with a little flaxseed or Indian meal, 
to give it a slightly greater consistence. Each poultice may be allowed 
to remain on the part for three or four hours. 

After the crusts have been entirely removed, and the inflammatory con- 
dition diminished by means of the emollient applications above recom- 
mended, the latter ma}^ be dispensed with entirety, or during the greater 
part of the da}^; or they may be used only during sleep, at which time 
they are usually best submitted to by the child. At this stage of the 
disease it becomes proper to make use of different lotions and ointments 
intended to modify the action of the diseased skin. 

The number of local remedies recommended in the books for eczema in 
its various forms, is however so enormous, that we shall refer only to those 
which we have ourselves made trial of and found useful, or which come 
from such sources as entitle them to our attention. 

The choice between the use of lotions or ointments must depend very 
much upon trials made in each particular case, since it will be found that 
some are irritated by all, even the mildest ointments, and bear lotions 
only, while in other instances exactly the opposite occurs. 

Amongst the lotions, the most soothing and beneficial are a weak solu- 
tion of borax containing morphia ; weak lead-water ; a sulphuro-alkaline 
lotion, as the following : 

R. — Potass. Carbonat., gss. 

Sulph. Sublimat., gj. 

Aquse Fluvial., f ^viij. 

Ft. Sol. 

Or weak solutions of bichloride of mercury, gr. ss to f^j, as Yan Swietan's 
liquor : 

R. — Hydrarg. Chloridi Corros., .... gr. xviij. 

Alcohol, . . . . . . . f^iij. 

Aquse Destillat., f^xxix. 

Ft. Sol. 

These lotions may be applied on pledgets of lint wetted with them, or, 
if such prolonged applications prove irritating, they may be used by 
merely washing the part with them for a quarter of an hour each time. 

We have ourselves usuall} r found that ointments afford more relief in 
such cases, and the one which we think the most appropriate, is the oint- 
ment of the benzoated oxide of zinc, rubbed dowm with a little alcohol. 
Among the other ointments highly recommended, are those containing 



LOCAL TREATMENT. 823 

oxide of lead or calamine ; or citrine ointment, diluted with two or three 
parts of simple cerate. 

When the eruption is confined to a rather small surface and is not very 
acute and rapid in its progress, or when the activity of the inflammation 
has been somewhat subdued, more powerful local remedies may be em- 
ployed. Among these may be mentioned a saturated solution of borax 
in dilute acetic acid; stronger solutions of corrosive sublimate; solutions 
of nitrate of silver, of from 2 to 10 grains to the ounce ; or such ointments 
as the citrine, either pure or mixed with an equal part of lard or simple 
cerate ; or, ointments containing protiodide of mercury : 

R. — Hydrarg. Protiod., . . . . . gr. xij. 

Camphorae, gr. v. 

Axungiae, §j.— - M. 

Apply twice daily. 
Or calomel : 

R.— Hydrarg. Chlor. Mitis, . . . . 9J. 

Camphora, ....... gr. v. 

Glycerine, fgj. 

Ungt. Aquae Kosar., ^j. — M. 

Tar ointment, or either of the zinc ointments may also be used. 

After the activity of the inflammation has been diminished by treat- 
ment or by time, and the disease tends to pass into a chronic form, it be- 
comes necessaiy to make use of more stimulating applications than those 
just named. The best of these remedies are those which contain alkaline 
substances, tarry substances, or mercury. 

The remedy from which we have obtained the most beneficial effects in 
such cases, is the spiritus saponatus kalinus of Hebra, which is prepared 
by dissolving soft (potash) soap in alcohol (in the proportion of two parts 
of the soap to one of alcohol), filtering the solution, and scenting it with 
spiritus lavandulse, or any other aromatic spirit : 

R. — Saponis Mollis, ^ij. 

Alcoholis, f^j. 

Misce, et cola. 

In the use of this application it is essential, as directed by Hebra, that 
the soap should be firmly rubbed into the eruptive patch by means of a 
piece of flannel or a brush, till the accumulated masses of epidermis are 
removed, and a little blood is seen to ooze from the red base which has 
thus been exposed. 

Other ointments and lotions containing alkaline substances are also 
recommended, such as those containing carbonate of potash, gr. xx to xxx 
to oj of lard (Neligan), or caustic potash, gr. ij to gr. x to f,5J of water. 
This latter application is especially useful in cases where the eruption 
is confined to limited patches, and is attended with much infiltration of 
the skin. If the stronger forms of the solution are used, they should, 
after being applied quickly by means of a brush, be washed off by a large 
brush w T etted with pure water. 



824 HERPES. 

Tarry applications also are among the most useful in the chronic form 
of eczema. They ma} r be made in the form of ointments, as the officinal 
tar ointment, or the following, recommended by Rilliet and Barthez as 
successful in their hands : 

R. — Vini Opii, fgss. 

Picis Liquidae, ...... 5vjss. 

Axungise, ....... ^j. — M. 

Or, the}^ may be combined with an alkali, as soft soap, as is done in Hebra's 
tinctura saponis viridis cum pice ; which is made by adding one part of 
tar to three of the spiritus saponatus kalinus. 

The tarry ingredient in these may be either common tar ; oil of cade 
(oleum cadinum, huile de cade), a product of the dry distillation of the 
wood of the juniperus oxycedrus ; oleum fag i, obtained from the beech ; 
or oleum rusci or betulse, which comes from the bark of the betula alba. 

When used in the form of soap, it should be rubbed firmly over the 
affected surface, or even be allowed to dry on. 

The forms of mercury best adapted to this stage are the nitrate, the 
protiodide, and the mild chloride, which may be combined with lard in a 
larger proportion than that recommended for an earlier stage of the dis- 
ease. 

In cases of eczema tarsi, attended with infiltration of the eyelids, 
McCall Anderson recommends that the eyelashes should be extracted, 
the ej^elids everted and a solution of caustic potash gr. v or x to f^j ap- 
plied and quickly washed off by a large brush. Care should be observed ' 
in case the edges of the e3 T elids are adherent in the morning, not to sepa- 
rate them rudely, but to moisten them with tepid water or milk and water, 
so as to soften the crusts. Afterwards an application of citrine ointment, 
diluted with about two parts of lard, should be made along the edges of 
the lids night and morning. 



ARTICLE II. 



HERPES. 



Definition; Varieties; Frequency Herpes is a non-contagious 

cutaneous disease, characterized by an eruption of vesicles assembled in 
groups on inflamed surfaces, of irregular size and shape, which are sepa- 
rated from each other by perfectly healthy portions of skin. The disease 
is usually acute in its course, seldom lasting more than two or three 
weeks, but it is not, as a general rule, accompanied by any severe consti- 
tutional symptoms. The separate vesicles composing the eruption last 
about ten da} r s, and then disappear by the absorption of their contents, 
by the drying up of the contained fluid without rupture of the vesicles, 
or by the rupture of the vesicles, the escape of the fluid, and the forma- 
tion of thin, brownish, or yellowish scabs. 



FORMS — SYMPTOMS. 825 

There are several different varieties of herpes, which have been well 
divided by Mr. TVilson into two groups, the phlyctenoid and circinate. 
The phlyctenoid group is characterized hj the irregularity of form ex- 
hibited by the eruption, and includes the variety called herpes phbycte- 
nodes. and the local forms, called according to their seat, labialis, nasalis, 
palpebralis, auricularis, praeputialis, and pudendalis ; whilst the circinate 
group is characterized by the arrangement of the vesicles in circles, and 
includes the herpes zoster, and iris. Of these different varieties we shall 
describe, as of importance in children, only the phlyctenodes, zoster, and 
iris. Herpes circinatus, formerly included in this group, will be found, 
described in the article on tinea. 

Herpes is quite a frequent disease in children, though one rarely of any 
considerable importance. 

Causes. — The causes of herpes are often obscure and uncertain, and 
in many cases entirely inappreciable. The disease is most common in 
persons who possess a delicate and irritable skin. The most frequent and 
most clearly ascertained cause is some disturbance of the digestive func- 
tions, and when there exist, in connection with this condition, irritations 
or inflammations of the respiratory mucous membrane, it is especially 
apt to be developed. Herpes phlyctenocles often follows exposure to a 
hot sun, while herpes labialis is frequently caused by exposure to a cold 
wind, especially when this occurs immediately after leaving a heated room. 
The latter variety also frequently accompanies coryza, angina, and stom- 
atitis, and appears often as a critical eruption in the course, and particu- 
larly at the termination, of fevers, catarrhs, and visceral inflammations. 

The usual exciting causes of the disease are irregularities in diet, ex- 
posure of the bod}' while in a heated state to cold and damp, local irritants, 
and bilious disorders of all kinds. 

Herpes Phlyctenodes. — This variety of herpes, unlike the other forms 
of the disease, may appear upon any part of the cutaneous surface, and 
does not assume a determinate shape. It may appear, indeed, upon 
several parts at the same time. It is usually, however, met with upon 
the upper parts of the body, and particularly the cheeks, neck, chest, and 
arms. It is rare to observe it on the lower extremities. 

We believe it to be a rare affection amongst the children of families in 
easy circumstances. The only examples that we have seen have been the 
result of poisoning by the different kinds of Toxicodendron. 

Symptoms. — The eruption appears in the form of vesicles, usually of 
very small size, looking like mere points, or attaining sometimes the size 
of a pea, which are seated in groups or clusters on inflamed patches of 
the skin, varying in size from that of a dollar to that of the palm of the 
hand. Sensations of heat, smarting, and itching, are often felt in the 
part where the eruption is about to show itself; and within a clay, usually, 
after these symptoms have been observed, or without them, the disease 
makes its appearance, exhibiting one or more red and inflamed surfaces, 
of an irregular or rounded shape, dotted over with projecting, globular 
vesicles, which are hard, resisting, and, on the first day, transparent, but 
which become, in the course of a day or two, turbid or lactescent. The 



826 HERPES. 

red color of the eruptive patch generally extends a short distance beyond 
the vesicles : the integument between the different patches retains, how- 
ever, in all cases, its healthy color and character. A sense of smarting 
and itching accompanies, as well as precedes, the eruption. On the second 
day of the eruption, the number of vesicles generally increases, aud they 
become full and distended. About the third or fourth day, the vesicles 
have become very turbid, and they begin to shrink. About the seventh 
or eighth day, they are usually transformed, by the drying up of their 
contents, into thin, brownish crusts, which fall off by desquamation about 
the tenth or twelfth day. There also remains, for a few days after the 
disappearance of the eruption, some redness of the surface, which sub- 
sides little by little. 

This variety of herpes is never accompanied by constitutional symp- 
toms of any severity. A very slight febrile reaction, some languor, loss 
of appetite, and thirst, are the only ones worthy of note. 

Herpes Labialis. — This is the most frequent of all the varieties of the 
disease. It is, as its name implies, a disease of the lips. Usually it is 
seated upon the line of junction of the mucous membrane with the in- 
tegument ; but it may affect either the former or latter alone. Though 
generally confined strictly to the lips, the eruption, in some instances, 
extends to the cheeks, chin, or alse of the nose. 

The disease begins generally with redness, heat, smarting, and painful 
tension of the portion of the lip upon which the eruption is about to 
appear. After a few hours, or a day, vesicles begin to show themselves 
upon the inflamed spot, and there is then observed a red, swollen, and 
shining point, upon which is seated a group of vesicles. The tumefac- 
tion and redness commonly extend some distance be3^ond the vesicles. 
The latter develop themselves rapidly, until five or six small, rounded 
vesicles, filled with a transparent fluid, are seen. The vesicles remain 
solitary, or several may unite together to form one of considerable size. 
After the complete development of the eruption, the burning pain which 
existed at first commonly subsides. The contents of the vesicles soon 
become turbid and lactescent, and are converted, by the third or fourth 
day, from a serous into a sero-purulent fluid, at which time, also, the ac- 
companying redness and swelling have, in great measure, disappeared. 
Soon after this, brownish crusts are formed by the drying up of the fluid 
of the vesicles, and these drop off usually about the seventh or eighth 
day. A slight redness remains for a short time at the point of eruption, 
and then disappears entirely. 

Herpes Zoster. — This variety of herpes is known also by the names of 
Zona and Shingles. It is of much less frequent occurrence, in this city, 
in children, than either the herpes labialis or circinatus. We have never 
as yet seen a case of it in a child, though Rilliet and Barthez state that 
they met with this form and the herpes labialis more frequently than any 
other. The peculiarity of the disease consists in the fact that the erup- 
tion appears in the form of a half zone, surrounding half the body, whence 
its name, herpes zoster, the latter word signifying a girdle or belt. 

The most frequent seat of zona is the base of the thorax, the disease 



SYMPTOMS. 827 

extending usually, in the form of a cincture, from the mesial line in front 
to the same point behind. It may, however, be developed either above 
or below the part just named, and, under these circumstances, is apt to 
extend towards or down the arm, or towards the thigh and down the leg. 
Still more rarely, it has been observed upon the neck, face, or scrotum. 
There is some doubt as to which side it is most disposed to attack. The 
half zone formed by the eruption is not composed of a continuous line of 
vesicles, but is made up of distinct patches of eruption, all following 
the same general direction, but divided from each other by portions of 
healthy integument. The eruptive patches may be very closely approxi- 
mated, or they may be separated by considerable spaces of skin un- 
touched by the disease. 

The disease is acute in its character, lasting, as a general rule, from one 
to three or four weeks. 

Shingles appear first, after some previous smarting and burning in the 
skin, in the form of irregular patches of a vivid red color, more or less 
widely separated from each other, and developed, one after the other, 
until one-half the bod}' is girdled by the eruption. In some instances 
the disease appears simultaneously at the two extremities of the zone, 
and is terminated b} T the gradual formation of successive patches between 
these two points. Soon after the appearance of the inflamed patches, 
numerous small, white projections can be seen, by careful examination, 
upon the red surfaces ; these increase rapidly in size, and are soon con- 
verted into distinct, transparent vesicles. The vesicles augment in size, 
and arrive, in the course of three or four clays, at their fullest develop- 
ment, when they are about as large as small or large peas, or, in some 
few instances, much larger. At this stage. of the eruption, the red sur- 
face upon which each group of vesicles is seated extends a slight distance 
beyond the patch, thus forming a kind of areola. 

After pursuing the course just described during four or five clays, each 
group of vesicles begins to subside. The redness of the inflamed patch 
diminishes ; the vesicles shrink, and become shrivelled ; their contents, 
which were transparent at first, become opaque, and finally they dry up 
and form small, dark-brown scabs, which fall off about the tenth or twelfth 
day, leaving behind reddish spots, which disappear little by little. 

The constitutional symptoms of herpes zoster consist usually of slight 
feverishness, languor, and the signs of gastro-intestinal irritation. The 
local symptoms are pungent and burning pain at the beginning of the 
eruption, and more or less severe tension, and sometimes acute pain, in 
the part upon which the disease is seated, which latter lasts, in some in- 
stances, throughout the course of the disorder, or even for some consider- 
able time after it has disappeared. 

Herpes Circinatus. — This variety of herpes has been called also ring 
herpes, herpetic ringworm, and vesicular ringworm ; it will be found de- 
scribed under the name tinea circinata in the article on parasitic diseases 
of the skin. 

Herpes Iris. — This is a very rare variety of herpes, one that we have 
never yet met with in children. It begins with small red spots, which 



828 HERPES. 

are soon surrounded by four or five rings of different shades of redness. 
About the second da}' of the eruption, the central red spots present in 
their centres one or more vesicles, and on the third and fourth days, 
vesicles of very minute size generally appear on the outer concentric 
rings. After two or three days, the fluid contained in the central group 
of vesicles, which was transparent at first, becomes turbid, and about the 
fifth or sixth of the eruption, it is absorbed, and the disease terminates 
by a slight desquamation. The vesicles formed on the outer ring undergo 
the same changes as those described as occurring in the central ones. In 
some instances, the vesicles open, and their contents escaping, form small, 
thin, and brownish scales, which fall off in ten or twelve days. 

Herpes iris may attack any part of the body, but is most frequently 
developed upon the face, hands, fingers, and neck. 

According to some dermatologists, as McCall Anderson, herpes iris is 
a parasitic disease and merely a form of tinea versicolor. 

Diagnosis. — The diagnosis of herpes is seldom attended with any diffi- 
culty. The small size of the vesicles, their globular shape, their number, 
their aggregation upon distinct patches of inflamed integument, and the 
slight degree of constitutional disturbance attendant upon the disease, 
all render the eruption unlike any other cutaneous affection, and there- 
fore easy of recognition. 

Herpes phlyctenodes might possibly be confounded by an incompetent 
observer with pemphigus. The recollection that the eruption in pemphi- 
gus consists of distinct bullae, much larger of course than the vesicles of 
herpes, while that of herpes phlyctenodes consists of numerous vesicles, 
much smaller than the bullae of pemphigus, and closely dotted over iso- 
lated red patches, will alwa} T s serve to distinguish the two affections. It 
might be mistaken also for eczema, when the vesicles of the latter are dis- 
posed, as sometimes, though rarely, happens, in groups. The distinction 
may be made, however, by attention to the facts that the eczematous 
vesicles are redder, less elevated, scarcely transparent, and that, though 
arranged in groups, they are confluent, whilst in herpes they are always 
distinct. 

Herpes labialis is not likely to be mistaken for any other eruption. 
Herpes zoster may alwaj^s be distinguished by the peculiar belted form 
assumed by the eruption. 

There is but one disease with which herpes iris is likely to be con- 
founded, — roseola annulata. The entire absence of vesicles in the latter 
affection will always, however, enable us to make the distinction. 

Prognosis. — The prognosis of herpes is alwaj^s favorable. It is never 
in itself a dangerous disease, though the variety called zona often causes 
much suffering, and is moreover usually the expression of a considerable 
disturbance of the general health. 

Treatment. — The different varieties of herpes seldom require more 
than the mildest treatment. In all, attention should be paid to the gene- 
ral health. The diet must be regulated according to the state of the 
digestive function. When constipation is present, especially if there be 
some febrile reaction at the same time, gentle laxatives ought to be ad- 



TREATMENT. 829 

ministered, such as sulphur, magnesia, syrup of rhubarb and magnesia, 
or castor-oil. If the skin be sallow, the tongue heavily coated, the breath 
foul, and the stools scanty and light-colored, or very offensive, small closes 
of blue pill in combination with rhubarb, or followed b} T rhubarb and 
magnesia, would be the most appropriate remedy. Excessive or fre- 
quently-repeated doses of aii3 r kind ought to be avoided, as the debility 
and gastro-intestinal irritation that so often follow such practice, are 
more injurious than the original disease. 

The local treatment of herpes is important, and is, indeed, in many 
cases, all that is necessary. 

Herpes pkfyctenodes requires nothing more than mucilaginous lotions, 
an occasional warm bath, or the frequent moistening of the eruption with 
a liniment made of equal parts of lime-water and sweet-oil. Herpes 
labialis, if it demand local treatment at all, may be relieved by the use of 
any mild lip-salve : a very good ointment is one composed of equal parts 
of Goulard's cerate and simple cerate, with a few drops of glycerine. Mr. 
"Wilson recommends the following ointment : 

R. — Unguent. Flor. Sambuci, . . . . ^j. 

Liq. Plumbi, f^j. — M. 

During the earl}' stage of herpes zoster, the local treatment should be 
such as will tend to alia}' inflammation and relieve pain. These effects 
may be obtained by applying compresses moistened with some kind of 
mucilage, such as barley-water, or decoction of flaxseed or slippery-elm 
bark, or with simple cold water, or with weak lead-water and laudanum. 
When the eruption is followed by excoriations or ulcerations, and the 
pain is severe, the latter may be allayed by the use of an ointment con- 
sisting of equal parts of Goulard's cerate and lard, either alone, or con- 
taining two or three grains of opium, or half a drachm of the watery ex- 
tract of opium. Underwood recommends, when the discharge has sub- 
sided, and the scabs have formed and become adherent, that they should 
be anointed twice daily with the ung. hydrarg. ammoniat. 

Herpes iris seldom requires any treatment. If any be determined on 
it should consist of alkaline lotions, or of water rendered slightly astrin- 
gent by the addition of alum, or sulphate of zinc. 



AETICLE III. 

SCABIES. 

Definition ; Synonymes ; Frequency. — Scabies is a contagious erup- 
tion of the skin, characterized by the formation of papules, vesicles, or 
pustules ; the vesicles being pointed, generally discrete, and usually pre- 
senting small red lines, of one or several lines in length, running off from 
them. The eruption is attended with severe itching, and is caused partly 
by the presence in the skin of a small insect, called the acarus scabiei, 
and partly by the scratching which the intolerable itching provokes. 



830 SCABIES. 

Causes. — Itch is a contagious malady, and is in all probability caused 
only by contact, either immediately with some person laboring under the 
disease, or with articles of clothing worn by an infected individual. 

It is much more frequently met with amongst the poor and destitute, 
whose habits are uncleanly, who live closely packed together in small 
and inconvenient houses, and in whom, therefore, the means of communi- 
cation are abundant, than amongst the easy classes of society, whose 
habits, and, consequently, liability to contact, are the opposite of those 
just named. 

The disease usually appears in children in from four to five days after 
the exposure to contagion. In healtlry, sanguine children, it often shows 
itself within a shorter time, — after two days, — while in those who are 
feeble and weakly, the period of incubation may be even longer than 
four of five days. 

Symptoms. — The first symptoms of itch appear in the part to which the 
cause, a contagious contact, may have been applied. In infants at the 
breast, it is usually first developed on the hips and thighs, as it is those 
parts that are most constantly in contact with the nurses who carry the 
child, and from whom young children generally receive the infection. In 
older children, the disease commonly appears first on the wrists and be- 
tween the fingers, and extends thence more or less quickly to the flexures 
of the elbows, and to the axillae and abdomen. It rarely or never attacks 
the face in adults ; but in children, even this part is not, according to M. 
Richard, exempt. {Trait. Prat, des Mai. des Enfants, p. 590.) 

The disease i£ alwa3 r s attended with severe itching, which, in infants, 
causes uneasiness and fretfulness, and in older children violent scratch- 
ing. The itching is increased by the heat of the bed-coverings, and is, 
therefore, most troublesome at night. The eruption appears in the form 
of more or less numerous vesicles, which are small, discrete, acuminated, 
and transparent at the top. The vesicles are at first of a faint rose color, 
and they contain a viscid, transparent serum. Their number is variable, 
being sometimes very abundant, and at others sparse. They either open 
spontaneously, or are soon broken by the fingers or clothes, and are followed 
by small, thin, slightly adherent scabs. In some instances the action of 
the nails causes slight effusions of blood, which dry into small bloody 
scabs, like those of prurigo, thus embarrassing, to a certain extent, the 
diagnosis of the disease. Sometimes, particularly when the inflammation 
attendant upon the eruption, or that caused by scratching, is marked, 
there are, intermingled with the psoric vesicles, pustules of impetigo, or 
perhaps papules of lichen, which tend like the sanguine crusts, just al- 
luded to, to render the diagnosis difficult. Indeed it is not strictly cor- 
rect to define scabies, as was formerly done, as a vesicular affection, since 
the eruption is papular in a very large proportion of cases. 

When a recent vesicle is carefully examined, there may generally be 
observed running off from it, in a straight, curved, or zigzag direction, a 
whitish or reddish line, like that produced by the scratch of a pin. This 
line marks the course of the fecundated female of the acarus scabiei in its 
burrowings under the epidermis, and is called the cuniculus, or burrow. 



SYMPTOMS — DESCRIPTION OF THE ACARUS. 831 

It varies in length from one or two, to five or six lines. At the point 
where it terminates opposite to the vesicle, there is usually to be seen a 
small rounded projection, deeper in color than the rest of the cuniculus, 
beneath which lies the insect. The acarns can often be found at this 
spot, and removed, by carefully introducing horizontally under the epi- 
dermis the point of a small needle, and by manipulation so as to. take off 
a small layer of the epidermis. The insect clings to the point of the 
needle, and can then be extracted from its lodgement. 

The number and extent of the vesicles vary greatly in different subjects. 
In some they are confined to limited surfaces, while in others, and par- 
ticularly in robust, sanguine children, and in those who are neglected and 
imperfectly cleansed, they extend to many different parts, or over the 
greater part of the body. 

Itch occasions in children much irritability and suffering, and when 
neglected may injure seriously the general health, and cause emaciation 
and debility. 

The acarus scabiei is an arachnoid insect, varying, according to Mr. 
Wilson's measurements, between T -J ? and ^\ of an inch in length, and 
between 3J3 and ^ of an inch in breadth. It is of a whitish and shining 
color, when examined with the naked e t ye, of a globular form, and is pro- 
vided with eight legs, four anterior and four posterior. A most accurate 
and minute account of the structure of the insect is given by Mr. Wilson 
in his work on diseases of the skin (1th Amer. ed., p. 139). Besides the 
female, which is found, as before stated, at the extremity, the cuniculus 
contains a varying number of ova, rarely more than twelve or fourteen ; 
there are in addition numerous little oval or round blackish spots, which 
are supposed to be excrement. These ova are about -g-j^ of an inch broad, 
and jijj of an inch in length, though their size varies according to their 
age. After the escape of the acarus the shell appears shrivelled, with two 
slits in it. 

Diagnosis. — The most characteristic marks of itch are the presence of 
the cuniculi and of the insect which causes the disease. If the acarus or 
its ova can be extracted from the skin, there will remain, of course, no 
doubt; and if the cuniculi be distinct and numerous, the diagnosis be- 
comes almost as certain as when the insect itself is obtained. Before en- 
deavoring to detect the cuniculi, it is always advisable to make the patient 
wash the part thoroughly. 

In doubtful cases, it has been recommended by Gull and Hilton Fagge 
to search for the ova in the crusts or the thickened and undermined 
cuticle in the neighborhood of the vesicles. In order to detect these, a 
small piece of the crust should be boiled in a solution of caustic soda, 3ss 
to f |j of water, until it is in great part dissolved ; the fluid should then 
be allowed to settle, the supernatant part decanted and the deposit ex- 
amined, which will, in cases of true scabies, be generally found to contain 
larvae, ova, or egg-shells. 

When, on the contrary, the insect cannot be found, and when the cu- 
niculi are absent or not distinct, the diagnosis becomes more uncertain. 
The diseases with which it is most likely to be confounded are eczema 



832 SCABIES. 

simplex, prurigo, and lichen simplex. From the former it may usually 
be distinguished with certainty by attention to the following points. In 
eczema the vesicles are flattened, or globular, scarcely raised above the 
surface, and they are collected together in clusters; in itch they are 
acuminated, elevated, and either entirely distinct, or much less confluent 
than in eczema ; in eczema there is a sensation rather of pricking than 
itching, whilst in itch the sense of itching is severe and distressing; and 
lastly, itch is communicable by contact, whilst eczema is never con- 
tagious. 

Prurigo begins with papules, which alwa} T s remain such. The scabs in 
prurigo are small and black, consisting of coagulated blood, caused to 
exude by the rubbing off of the top of the papule ; while in scabies the 
scabs are more like thin, 3 T ellowish, and friable scales. The seat of the 
two eruptions is different. Prurigo is developed upon the back, the 
shoulders, and upon the extensor surfaces of the limbs ; while itch ap- 
pears first about the thighs and buttocks, between the fingers, or about 
the flexures of the joints. Lastly, prurigo is never, itch alwaj^s, con- 
tagious. 

Lichen simplex is a papular disease, in which the papules are closely 
agglomerated, while in scabies the papules, if present, are coujoined with 
vesicles, and are discrete. Lichen sometimes affects the hands, and might 
then be mistaken for itch ; but in the former the eruption affects the dor- 
sal surface of the hands, while in the latter it appears in the interspaces 
of the fingers. Lichen is never attended, as itch alwaj'S is, by severe 
pruritus. Attention to these points of difference will almost always render 
the diagnosis of the two diseases very easy and certain. 

When, as sometimes happens, scabies is intermingled with other erup- 
tions of the pustular, papular, or vesicular kind, the diagnosis can be ar- 
rived at with certainty, only by careful attention to the cuniculi, or by 
the detection of the insect. When neither of these characteristic condi- 
tions are present to mark the true nature of the disease, there will always 
remain some doubt as to the diagnosis. 

Under these circumstances, however, it is advisable to treat the case 
as one of scabies, since the specific remedies for this affection will not be 
injurious, even if they do not speedily cure the eruption. 

Prognosis. — Itch is a mild disease, which never disturbs the health 
seriously. 

Treatment. — If the inflammation produced b} r scratching be very 
severe, it ma} T be necessary to allay it by emollient application, though 
this rarely happens. 

In children as in adults, the best treatment for itch is the use of sulphur 
by inunction. The ungt. sulphuris of the American Pharmacopoeia, con- 
sisting of one part of sulphur to two of lard, should be well rubbed into 
the skin before a fire, morning and evening, for two days. The child 
should be kept in a flannel gown, and in bed, during this treatment. On 
the morning of the third day, the skin may be washed clean with soap 
and water, or by immersion in a warm bath. This plan rarely fails to 
effect a cure. Should it happen, however, to fail, the treatment must be 



TREATMENT. 833 

repeated. Before the application of this or any of the other ointments, 
the surface should be well scrubbed with soap and hot water, so as to 
cleanse and soften the skin. 

It also increases the effect of the sulphur, to conjoin with it some alka- 
line substance, as in the various sulpho-alkaline ointments and lotions, of 
which the following are among the best : 

TTng. Sulphtjris cum Potassa (Wilson). 



R 


—Sulphuris Subliraati, .... 
Potassae Carbonatis, .... 
Unguenti Benzoati, 
Olei Anthemidis Essentialis, . 

Helmerich' s Formula. 


• 3J. 

. f^ss.— M. 


R. 


— Sulphuris Sublimati, .... 
Potassae Carbonatis, .... 
Adipis Preparati, 


• Eh 

. aviij.-M. 


R. 


Vlemingkx's Formula. 

— Calcis Vivi, 

Sulphuris Sublimati, .... 
Aquae Fontanae, ..... 


. fgxx. 



Boil in an iron vessel, and stir with a wooden spatula to a perfect union. 

These are all quoted in the proportions directed for adults, which are 
much too active to be applied to the delicate skin of children ; they should 
therefore, be diluted one-half at least. 

Anderson recommends the nse of oil of cade or tar, combined with the 
sulpho-alkaline ointments. 

As the nse of the sulphur ointment is sometimes objected to in private 
families, on account of its disagreeable odor, various substitutes have 
been recommended. Mr. Wilson states that he found camphor dissolved 
in oil, in the proportion of one drachm to the ounce, answer every pur- 
pose of eradicating the disease ; and Dr. Coley (Pract. Treat, on Bis. of 
Children, Phil, ed., 101) speaks highly of an ointment composed of a 
drachm of iodide of potassium to an ounce and a half of lard, of which a 
little is to be applied all over the body, except the head and face, every 
night. 

Ointments containing carbolic acid or petroleum are also used with 
good effect. 

The use of stavesacre and hellebore has lately been revived, and ap- 
parently with good success ; and Anderson highly recommends an oint- 
ment made by melting together one part of liquid styrax, with two of 
lard. 

The disease rarely requires any constitutional treatment. If, however, 
any complication exist, or the general health be deranged in any way r 
such measures as may be necessary for the removal of either of these 
conditions should be employed, in connection with those proper for the 
specific disease. 



834 PEMPHIGUS OR POMPHOLTX. 

CHAPTER III. 

BULL^l. 
AKTICLE I. 

PEMPHIGUS OR POMPHOLYX. 

Definition ; Synonymes ; Varieties ; Frequency. — Pemphigus is 
an eruptive disease, characterized b} f the presence on one or several parts 
of the body, of more or less numerous bullae of considerable size, nearly 
always isolated, resting upon circular or oval erythematous patches, about 
as large or somewhat larger than the bases of the bullae themselves. The 
bullae form in the course of a few hours, and contain at first a limpid 
serum, which soon becomes reddish or turbid ; they terminate by desicca- 
tion and the formation of thin crusts, or by rupture, and the escape of 
their contents, when there remains behind a superficial ulceration. 

Authors formerly described numerous varieties of this disease, and 
gave to some of them the title of pompholyx. Of late 3 T ears, however, 
these have been reduced to a few forms, and we shall confine our remarks 
to those most apt to occur in children. The only variety which is really 
important in children is the pemphigus acutus. The pemphigus chron- 
icus, a dangerous and not unfrequent variety in old people, is so rarely 
met with in early life, as to make it unnecessary for us to describe it. 
Another species of bullar eruption, formerly called pemphigus infantilis, 
is now more properly classed as rupia escharotica, under which title we 
shall give an account of it. 

Pemphigus is not unfrequently met with in young children who become 
the inmates of hospitals, almshouses, and foundling hospitals, and 
amongst the poor and destitute classes of large cities. Still it cannot be 
said to be a frequent disease. 

Causes. — The causes of pemphigus are often obscure or entirely inap- 
preciable. It is usually supposed, however, to depend, in children, upon 
the influence of the act of dentition, on disturbances of the gastro-intes- 
tinal tube brought about by improper food or over-feeding, and on gene- 
ral disorder of the nervous system. It is one of the most frequent erup- 
tions in congenital sj-philis (seep. 659), and is not rarely present at birth 
in such cases. 

Symptoms. — Acute pemphigus ma} T be confined to a very small portion 
of the cutaneous surface, or it may affect several regions of the body at 
once. It is usually attended with sjnnptoms of constitutional disturbance, 
which, especially in veiy young infants, may be slight, consisting merely 
of general uneasiness, languor, and some acceleration of the pulse ; or they 
may be severe, exhibiting in such cases. a dry and burning skin, frequent 
pulse, thirst, and loss of appetite. 

After the above constitutional symptoms have lasted one, two, or three 
days, the eruption makes its appearance in the form of small circular 



DIAGNOSIS — PROGNOSIS — TREATMENT. . 835 

red spots, which increase in size, and soon exhibit a bleb or bulla rising 
in the middle or over the whole of the red spot. The vesicle commonly 
appears a few hours after the red patch, and consists of an elevation of 
the cuticle by an effusion of serum beneath it. The bulla rapidly distends 
by the increase of the serous effusion, until it attains the size of a pea, 
a hazel-nut, or a large walnut. It is of a circular or oval form, and may 
be confined to the centre of the erythematous surface on which it rests, 
being surrounded in such cases b} r a more or less wide red line of inflam- 
mation, or it may occupy the whole or nearly^ the whole of the red patch, 
under which circumstances it entirely conceals the latter, or is surrounded 
by a very narrow red ring. The color of the areolae around the bullae is 
very bright during the first day of the eruption, while the integument be- 
tween remains perfectly healthy. 

The fluid contained in the bullae soon becomes turbid; the bullae be- 
come wrinkled, and usually burst after one or two days, and are replaced 
by thin yellowish or brownish scabs. The crusts begin to form before 
the redness of the integument has disappeared. In some instances the 
bulla? do not break, but their contained fluid becomes yellowish in color, 
and then turbid, it diminishes by absorption, and, at the end of about a 
week, dries into a thin dark-colored scab. The crusts usually fall off in 
the course of two or three weeks, leaving the skin beneath of a reddish 
color, but in other respects healthy. The whole duration of the disease 
is commonly from one to three weeks, the time in each case varying with 
the mode of the eruption; when all the bullae appear simultaneously, sel- 
dom lasting more than one or two weeks ; while in cases in which they 
appear at successive periods, lasting three or even four weeks. 

Diagnosis. — The diagnosis of pemphigus acutus is seldom difficult. 
The large isolated bullae, seated on inflamed patches of the integument, 
filled with transparent serum, and followed by thin lamellated scabs, are 
unlike almost any other kind of eruption. From rupia, the other form of 
bullar disease, it is to be distinguished by the smaller number of blebs in 
the former, by their greater flatness, and by the facts that these are fol- 
lowed by true ulcerations, and by thick and prominent scabs. 

Prognosis. — Acute pemphigus is rarely dangerous when it exists with- 
out complications. When, however, it is very extensive, and accompa- 
nied with severe constitutional symptoms, and particularly when it exists 
in connection with other diseases, or occurs in a child whose health has 
been broken down by unwholesome hygienic influences, it may assume a 
dangerous character, and the prognosis should, therefore, always be 
guarded under such circumstances. 

Treatment. — Simple acute pemphigus requires, as a general rule, no 
other treatment than attention to diet, and regulation of the digestive 
function. When constipation is present, this should be overcome by 
means of simple enemata, or by the use of some mild laxative, as manna, 
spiced syrup of rhubarb, or very small doses of castor-oil. If the dis- 
charges be too frequent, they should be restrained by^ the use of opium 
in doses proportioned to the age of the child. In young infants, it will 
often be found that the gastro-intestinal secretions are of an acid and 



836 . rupia. 

irritating character. This condition may be treated with small closes of 
paregoric or laudanum, combined with lime or magnesia-water, or with 
soda. The diet must be managed according to the state of health of the 
child. For an infant, a good breast of milk is, of course, the best treat- 
ment in the world. For older children, the diet ought to be light and 
unirritating, but, at the same time, nourishing and strengthening. 

The local treatment should consist, in the early stage, of an occasional 
warm bath. When the bullae have fully formed, the} 7 ought to be punc- 
tured, and the fluid gently pressed out, care being taken not to remove 
the cuticle, as this forms the best possible dressing for the inflamed in- 
tegument. When the bullae are followed by excoriations, these may be 
dressed with an ointment consisting of equal parts of Goulard's cerate 
and simple cerate, made a little soft b}~ the addition of glycerine, or with 
carrot or elder-flower ointment, or with Turner's cerate. 

When the child shows signs of debility during the progress of the dis- 
ease, and also when the eruption tends to assume a chronic course, the 
treatment ought to be tonic and invigorating. It should consist in the 
use of a nutritious diet, and in the exhibition of tonics, as Huxham's 
tincture of bark, in small doses, quinia, cod-liver oil, or in the use of 
wine-whey, or small quantities of brand}'. 



ARTICLE II. 



RUPIA. 



Definition ; Varieties. — Rupia is an eruptive disease, characterized 
in its early stage by distinct, somewhat flattened bullae, of more or less 
considerable size, containing at first a serous, and then a purulent or 
blackish fluid : at a later period the disease exhibits very thick scabs, and 
still later, ulcerations. 

There are three varieties of this eruption : rupia simplex, rupia promi- 
nens, and rupia escharotica. The latter variety was formerly described 
under the title of pemphigus infantilis and pemphigus gangrenosus, and 
is known in Ireland under the different names of white blisters, eating 
hive, and burnt holes. It is the most important variety of the disease in 
young children. 

Causes. — Rupia is most apt to occur in weakly, badly-nourished, and 
scrofulous children, and seems to depend, therefore, upon that state of 
debility and exhaustion of the general health, which results from exposure 
to unfavorable hygienic conditions, which follows exhausting diseases, or 
which exists as a consequence of some hereditaiy taint. 

Symptoms. — Rupia simplex begins almost always on the inferior ex- 
tremities, or more rarely on the trunk or arms, without previous inflam- 
mation, in the form of small, flattened bullae, of about three or four lines 
in diameter. The bullae contain at first a serous and transparent fluid, 



SYMPTOMS. 837 

which soon becomes thicker, and is converted into pus. At an early 
period they shrink and become wrinkled, their contained fluid hardens 
and is converted into rough, brownish scabs, which are alwa}^s thicker at 
the centre than on the edges, and which leave beneath, after their fall, 
superficial ulcerations. These ulcerations either soon cicatrize and dis- 
appear, or are covered by fresh scabs. After the fall of the final scabs, 
there yet remain, for some time longer, dark brown or livid spots, wmich 
gradually fade and disappear. 

Rupia prominens exhibits the same general characters as the preceding 
variety, but with more marked and peculiar features. The eruption com- 
mences with a circumscribed inflammation of the skin, on which inflamed 
spot soon appears a bulla filled with j^ellowish serum, or sometimes with a 
blackish fluid, which rapidly hardens into a brownish or blackish wrinkled 
crust. The crust is surrounded by an erythematous areola, formed by 
the extension of the cutaneous inflammation beyond the circumference of 
the scab. Upon this areola a fresh elevation of the cuticle, by purulent 
deposit, often takes place, which, by its desiccation, adds to the size of 
the crust. This successive increase at the margin of the scab enlarges it 
in breadth, and, at the same time, raises the height of its centre, so as to 
give it a peculiar and characteristic appearance, and causes it to resemble 
very closely the shell of a limpet or oyster. The scabs thus formed 
usually adhere to the surface beneath with much tenacity, and remain 
attached for a variable, and, as a general rule, considerable length of 
time. When at length they fall of, or are removed, there are left beneath 
ulcers of variable depth and extent, which are either covered by fresh 
crusts, or, as more frequently happens, remain open, presenting a foul 
surface of a livid red color, with thickened edges. The ulcers are diffi- 
cult to heal, and, after cicatrization, leave livid or purplish stains, which 
often remain for months. The number of bullae is usually small, there 
being generally one at its height, and one or two about to appear, or on 
the decline. 

Rupia Escharotica. — This variety of rupia, formerly described as be- 
longing to the class pemphigus, and then called pemphigus infantilis and 
gangrenosus, differs in some respects from the other varieties of rupia, 
and particularly in the absence of the thick and projecting crusts, which 
characterize rupia simplex and prominens. It occurs chiefly amongst 
cachectic children, appearing usually in the period between birth and the 
first dentition. It is seated generally upon the neck, chest, abdomen, 
scrotum, or inferior extremities. 

The eruption begins in the form of purplish or livid spots, raised slightly 
above the level of the skin. Upon these spots the cuticle is soon elevated 
by a serous fluid, so as to form small bullae, which become rapidly larger, 
until they attain their full size. The bullae are smaller than in the other 
varieties of rupia ; they are irregular in shape, flattened on the top, and 
are surrounded by purplish areolae in the early stage of the eruption ; the 
fluid they contain becomes, at an early period, turbid and dark-colored, 
or almost black. The bullae soon wrinkle, burst, and leave ulcerated sur- 



838 rupia. 

faces, which are painful, often covered with sloughs, secreting a sanious 
and fetid pus, and difficult of cure. 

Soon after the formation of the ulcers, a fresh crop of bullae, forming 
a new eruption, often appears and passes through the same phases as the 
first, thus prolonging and extending the disease. This form of rupia is 
attended with much pain, with fever, sleeplessness, restlessness, and often 
ends fatally from the severe and continued irritation kept up by the dis- 
ease. In cases ending favorably the process of cicatrization is always 
slow and difficult. 

Diagnosis. — Rupia is likely to be confounded only with pemphigus and 
ecthyma. Pemphigus is to be distinguished from rupia by the larger size 
and greater distension and prominence of its bullae ; by the fact that the 
contained fluid of the latter is serous and transparent in pemphigus, in- 
stead of being turbid and sanguinolent, as in rupia ; by the different 
character of the crusts, which, in pemphigus, are thin and lamellated, 
while in rupia they are thick and rugous ; and, lastly, by the deep and 
unhealthy-looking ulcerations that follow rupia. 

Ecthyma is unlike rupia in being a pustular disease from the first. 
Moreover, the pustules of ecthyma are surrounded by a highly inflamed 
areola, which is not the case in rupia, while the crusts in the former dis- 
ease differ from those of the latter in being smaller, harder, more irregular, 
and more adherent. 

Prognosis. — Rupia simplex and prominens, though tedious and slow 
of cure, seldom prove fatal, while rupia escharotica is alwa3 r s dangerous, 
and in very weakly children, especially when these are exposed to bad 
hygienic conditions, very generally ends unfavorably. 

Treatment. — The most important point in the treatment is to attend 
to the hygienic state of the patient. When the child is living in an un- 
healthy house, or a close and confined room, it should be removed, if 
possible, to a more salubrious position, or to a larger and well-ventilated 
room. The diet ought to be such as to invigorate the strength, and pro- 
mote the nutrition of the bod} r . For an infant who is fed upon artificial 
food, or who is suckling a nurse of doubtful health, the best remedy in 
the world is a fresh and full breast of milk. If a nurse cannot be pro- 
cured, the diet must be most carefully regulated in accordance with the 
principles already detailed in full in the article on thrush, at page 297. 
While the diet is thus attended to, it is necessary to watch the state of the 
digestive organs, and if there be either constipation or diarrhoea, these 
must be overcome by suitable remedies. Tonics and stimulants are 
always advisable in this disease, and may consist either of brandy or wine, 
given alone, or in connection with Huxham's tincture of bark, extract of 
cinchona, small doses of quinia, iron, cod-liver oil, or any other remedy 
of this kind that may be preferred. 

Rupia simplex and prominens are to be locally treated in the early 
stage by opening the bullae as soon as they form, and covering them with 
dry lint and a light bandage, or with the water-dressing. The ulcerations 
that follow the bullae may be treated with Goulard's ointment, applied on 
pieces of fenestrated lint, and by washing occasionally with lime-water, 



ECTHYMA — CAUSES. 839 

or with weak solutions of alum, copper, zinc, or nitrate of silver. At a 
later period of the disease, when the ulcerations are covered with the 
characteristic thick crusts, these are first to be removed by means of 
poultices of bread-and-water, or flaxseed meal, and the surfaces beneath 
them treated with the applications recommended above. When the ulcer- 
ations are very obstinate and difficult to heal, they should be modified by 
occasional touchings with nitrate of silver, either pure or in strong solu- 
tion, or with dilute nitric or muriatic acid. 

Billard recommends that the ulcerations should be dusted with pow- 
dered alum or cream of tartar, and Rayer also speaks very highly of the 
last-named application. 

Dr. Stokes found that the best treatment in epidemic rupia escharotica 
was an ointment of the scrophularia nodosa, made by stewing the small 
leaves of the plant in as small a quantit}^ of unsalted butter as may be 
sufficient to prevent their scorching. The ointment is to be warmed 
until it becomes quite thin, and then applied by means of a brush, after 
which the surfaces are to be covered with lint smeared with the same 
ointment. The dressing is to be renewed every six hours. 



CHAPTER IV. 

PUSTULES. 
ARTICLE I 

ECTHYMA. 

Definition; Synonymes; Varieties. — Ectlryma is an eruption char- 
acterized by prominent, rounded, and usually discrete pustules of con- 
siderable size, with hard and inflamed bases. The pustules are followed 
by thick, brownish crusts, which leave on their fall a reddish mark, or 
more rarely a superficial ulcer or a true cicatrix. 

Ecthyma has been called also phlyzacia. There are two varieties of 
the disease to which children are subject, ecthyma vulgar e or acutum, 
and ecthyma infantile. 

Causes. — The most frequent causes of ecthyma are the application of 
irritating substances to the skin, such as croton-oil and tartar emetic 
ointment, and the presence of other eruptions upon the skin, particularly 
small-pox, measles, scarlet fever, herpes, or scabies. The causes just 
named give rise to the variety called ecthyma vulgare, which, it may be 
well to state in this place, is of an acute character, and has therefore been 
called by some writers ecthyma acutum. The other variet}^ of the disease, 
ecthyma infantile, is a chronic affection, and occurs almost always in 



840 ECTHYMA. 

feeble, badly nourished, and cachectic children, and in those whose health 
has been injured and broken down by exhausting diseases, and particu- 
larly by disorders of the gastro-intestinal apparatus. 

Symptoms. — Ecthyma vulgare occurs most frequently on the extremi- 
ties and neck, and more rarely on the trunk of the body. It appears in 
the form of small, red, and circumscribed spots, projecting above the 
surface of the skin, hard to the touch, and accompanied by smarting and 
often severe pain, and by soreness on pressure. The centre of the spots 
is soon elevated into a pustule, filled with a purulent fluid. The size of 
the pustules varies, but is usually about that of half a pea. Each pustule 
is generally surrounded by a hard base of a bright red color, constituting 
an areola, while, in some instances, the whole of the red elevation is 
covered by the pustular formation. The pustule remains unchanged 
usually for three or four days, and more rarely for a week, and is then 
converted, by the drying up of the effused fluid, into a thinnish brown 
scab, which drops off after a few days, and leaves a congested purple 
spot that remains for some time longer. In other instances, the pustule 
breaks and leaves a small ulceration which terminates with a slight cica- 
trix. The eruption is commonly successive, and is seldom accompanied 
by any febrile reaction. 

Ecthyma infantile is much more frequently met with than the other 
variety of the disease, and occurs in a single, or oftener in successive 
eruptions, in feeble, badly-nourished, and cachectic children. It appears 
on the neck, shoulders, arms, and chest, and especially upon the lower 
extremities. It is often connected with some chronic disorder of the di- 
gestive or respiratory apparatus, and is developed during the state of de- 
bility and exhaustion to which children are reduced by those affections. 

The pustules of ecthyma infantile are of variable size, some being small, 
and others as large or larger than a sixpence. They are circular in form, 
and surrounded by an areola of a red or purplish tint ; the fluid which 
the}' contain is generally not very thick, and is of a dark or sanguinolent 
appearance ; they terminate by the formation of a dark and adherent 
crust, by absorption of the contained fluid and a kind of desquamation, 
or by a blood}* excoriation, or true ulceration, which are followed by a 
deep stain upon the skin or a true cicatrix. 

Diagnosis. — Ecthyma is more likely to be confounded with rupia, than 
with any other disease. The pustular character of ectlryma, from the 
very beginning, will, however, almost always enable us to distinguish it 
from the broad and distended bulke of rupia, filled with sero-purulent 
fluid; and the difference between the two becomes still more marked, 
when we recollect the hard and inflamed bases on which the pustules of 
ecthyma rest, and the shapeless crusts and superficial excoriations of that 
disease, instead of the projecting, rugous, and imbricated scabs, and deep 
ulcerations of rupia. Ecthyma is not at all likely to be mistaken for the 
small and numerous pustules of impetigo, or the umbilicated ones of 
small-pox. 

Prognosis. — Ecthyma is never a dangerous disease in itself. If any 
danger accompany it, it arises rather from the enfeebled and disordered 



TREATMENT. 841 

state of the general health under the influence of which it is produced, 
than from any injury caused by the eruption. The prognosis must de- 
pend, therefore, upon the state of the general health existing during the 
attack of the disease. 

Treatment. — In both varieties of ecthyma, attention to the general 
health of the patient constitutes the most important point in the treat- 
ment. In the acute form, mild laxatives, small doses of some alterative, 
as the hydrargyrum cum creta or sulphur, the use of a nutritious and 
wholesome, and especially of an unstimulating diet, and the local appli- 
cation of mucilaginous infusions, or of a mild and cooling ointment, as 
Goulard's cerate, Turner's cerate, or the carrot, cucumber, or elder-flower 
ointments, with occasional warm bathing, are all that the case demands. 
In the ectlryina infantile, the attention of the physician should be directed 
towards the restoration of the general health, which, as stated above, is 
always more or less deteriorated. As this deterioration depends usually 
upon the exposure of the child to unwholesome hygienic influences, and 
a consequent unhealthy state of the digestive and nutritive functions, it 
is of primary importance that these should be early attended to. The 
patient ought to be placed in a healthy and well-ventilated apartment ; 
the clothing must be regulated according to the age of the child, and the 
season of the }'ear ; and, what is most important of all, the diet ought to 
be such as is digestible, suitable to the age, and, at the same time, 
nourishing and strengthening. The internal remedies must consist of 
tonics in all cases, and, when the digestive power and general strength 
are reduced much below the normal standard, of stimulants. The best 
stimulant is old and pure brandy, either given mixed with water, three 
or four times a day, or combined with the food. The best tonics are, in 
most cases, some preparation of iron, and the one we prefer is the iodide, 
given mixed with syrup of ginger, or, when the bowels are not too irri- 
table, with small quantities of the compound syrup of sarsaparilla, or cod- 
liver oil. When, for any reason, iron is not given, quinia, or extract of 
cinchona, may be substituted. While these remedies are being employed, 
or prior to their administration, the gastro-intestinal functions ought to 
be carefully regulated by the use of mild laxatives when the bowels are 
constipated, or by some kind of astringent when they are loose and dis- 
ordered. 

The external or local treatment must consist in the use of mild demul- 
cent applications, or of soothing or cooling ointments, during the pustular 
stage of the eruption. When unhealthy excoriations or ulcerations follow 
the pustules, these may be brought into good condition by the employ- 
ment of weak solutions of nitrate of silver or sulphate of zinc, or of a very 
weak lotion of nitric or muriatic acid. 



842 STROPHULUS. 



CHAPTER V. 

PAPULES. 
ARTICLE I. 

STROPHULUS. 

This is a form of papular eruption which some writers regard as a 
variety of lichen, giviug to it the name of lichen strophulus. It, however, 
differs somewhat in its characters from the lichen of the adult, and, as it 
is peculiar to children, deserves a separate consideration. 

Strophulus is a disease affecting chiefly infants at the breast, charac- 
terized by a more or less extensive, and sometimes a general eruption of 
papules, which are whiter or redder than the surrounding skin, and are 
accompanied by more or less irritation and itching. 

Its causes are various disturbances of the digestive apparatus in very 
young infants, and in older ones the effort of the first dentition. 

Varieties and Symptoms. — The strophulus intertinctus, or red gum, 
consists of an eruption of prominent pimples of a vivid red color, scat- 
tered here and there over different parts or the whole of the body, and 
intermingled with small erythematous patches. The eruption remains 
upon the skin for some time, the papules disappearing and reappearing 
in successive crops, for a week or two, or more, until they terminate by 
desquamation. It is most common upon the cheeks, backs of the hands, 
and forearms. 

In strophulus confertus, the papules are much smaller, more closely 
aggregated, much more numerous, and more confluent, than in the first 
variety, and they constitute a more severe eruption. It may be distrib- 
uted over the whole surface, but is more commonly limited to a single 
spot, or to several regions, as the face, breast, or arms. The eruption is 
less vivid, but more lasting than that of the strophulus intertinctus, and 
usually reaches its height in twelve or fourteen daj^s, and then subsides. 

In strophulus volaticus, the papules, which are of a vivid color, are dis- 
posed in small, not very numerous, circular groups, scattered over the 
surface of the bocty, but met with most frequently on the cheeks and arms. 

The two remaining varieties, strophulus albidus or ivhite gum, and 
strophulus candidus, are both characterized b}^ whitish instead of red 
papules. In the former, the papules are white, minute in size, and sur- 
rounded each by an areola of a faint red color ; they appear usually on 
the face, neck, and breast, and continue for some length of time. In the 
latter, the papules are much larger, broader, more hard and tense, and 
are unaccompanied by any redness. They last usually about a week. 
This eruption is most common during dentition. 

Diagnosis. — There is no difficulty in distinguishing strophulus, as it is 
the only papular eruption to which infants are subject. The absence of 



LICHEN. 843 

general symptoms and the extreme mildness of the disease are amongst 
its chief characters. It must be remembered that we onty regard such 
papular eruptions as are unassociated with exudation or eczematous 
patches elsewhere on the surface as true instances of strophulus, since 
papules in all respects resembling those of this disease are to be frequently 
observed in cases of eczema papillosum. 

Prognosis. — The eruption is never attended with any danger. If se- 
vere symptoms happen to coincide with it, they must depend on some 
other causes than the cutaneous affection. 

Treatment. — As a general rule, strophulus needs no treatment what- 
ever. In infants within the month, the irritation of the skin, if it be such 
as to disturb the comfort of the child, ma}^ be allaj^ed by the use of the 
tepid bath, and by dusting with some mild powder, or by anointing with 
cold cream, glycerine and cold cream, simple cerate', or cocoa-butter. 
When any marked disturbance of the digestive apparatus is present, this 
should be attended to bj r the administration of mild laxatives, and of 
tonics, with some preparation of iron, as the tartrate or superphosphate. 

In older children, in whom the disease appears to be associated with 
dentition, the local means spoken of above may be employed, while at 
the same time the gums should be lanced, if necessar}^ and any gastro- 
intestinal disturbance removed by appropriate treatment. 



AKTICLE II. 

LICHEN. 

In children the lichenoid eruption takes so constantly the form of stro- 
phulus, that we deem it unnecessary to give a separate description of the 
former disease, with the exception of one of its varieties, the lichen tropi- 
cus. ^N"o doubt cases of lichen simplex do occasionally occur in children 
as tbe} r approach the age of adolescence, but since the disease resembles 
so closely in its characters, and requires the same treatment as strophu- 
lus, what has been said in regard to that disease will perfectly well apply 
also to lichen. Of lichen agrius, a not uncommon and severe form of the 
eruption in adults, we have never seen an example in a child. 

Lichen Tropicus, or Prickly Heat. — This is a form of lichen simplex 
which occurs principally in hot climates, and during the hot summer sea- 
son of the more southern temperate climates. It is a very common erup- 
tion at all ages of childhood, from early infancy upwards, in this city, 
and in most of our Middle and Southern States, and is commonly known 
by the name of prickly heat. 

The chief cause of lichen tropicus is apparently the action upon the 
cutaneous surface of a high temperature, aided, no doubt, b}^ the dis- 
turbances of the digestive function so apt to occur under the influence of 
that condition of the atmosphere. Yery warm clothing, and particularly 



844 PRURIGO. 

the presence upon the skin of thick rough flannels, is apt to develop the 
eruption. 

Symptoms. — The eruption of prickly heat consists of numerous small 
papules, few of them being larger than a pin's head, scattered more or 
less thickly over the affected surface. The pimples are of a red color, 
which is more or less bright in tint, according to the extent and intensity 
of the eruption. The skin between the papules retains its natural appear- 
ance when the eruption is but slight or moderate ; but when this is co- 
pious and severe, it assumes a faint reddish appearance, owing no doubt 
to the activity of the circulation in the part. 

The eruption is most abundant on the parts covered by the dress, or 
rubbed by the edges of the dress, particularly about the neck, upper part 
of the chest, and on the arms and legs. We have sometimes seen it 
covering the greater part of the body. It is alwa} r s attended with more 
or less itching, burning, and pricking, which, in older children, cause 
much fretfulness and scratching, and in those who are younger, restless- 
ness, woriying, and more or less disturbance of the sleep. The disorder 
usually remains stationary for several days, and then disappears gradu- 
ally without desquamation or other change in the skin ; or, it subsides 
and increases, or disappears and returns, with the rising and falling of 
the temperature, or without any very evident cause, until at last it ceases, 
not to appear again. When the eruption lasts many daj T s, it is almost 
always accompanied by a slight scaly desquamation of the tops of the 
pimples. 

The diagnosis of this form of eruption is never difficult. Its occurrence 
during hot weather, the character of the papules, their minuteness and 
abundance, and the entire absence of constitutional disturbance, will 
alwaj^s render it easy of recognition. 

Treatment. — Lichen tropicus is usually regarded as a salutarj^ erup- 
tion, and as not therefore to be interfered with Iry treatment likely to 
repel it. In fact, it never needs a\\y treatment, except when veiy abun- 
dant, and when it anno} T s the child by the heat and itching it occasions. 
Under these circumstances, the skin should be dusted with lye-meal, or 
anointed two or three times a d&y with some mild ointment, as, for in- 
stance, one consisting of glycerine and cold cream or lard, or the benzo- 
ated zinc ointment ; or, the child may be bathed once or twice a day in 
warm water containing bran, slippery-elm, or some other mucilaginous 
substance. 



AETICLE III. 

PRURIGO. 



Definition; Frequency. — Prurigo is characterized b} 7 an eruption, 
more or less extensive, of isolated papules, which, larger than those of 
strophulus, unattended with any change in the color of the skin, and de- 



CAUSE? — SYMPTOMS — DIAGNOSIS — PROGNOSIS — TREATMENT. 845 

veloped usually on the extensor surfaces of the limbs, give rise to the 
most violent and distressing itching, a symptom which constitutes one of 
the most marked features of the disease. Wilson includes it among the 
nervous affections of the skin, and attributes it usually to nervous debility, 
with an impaired state of the nutrition and innervation of the skin. 

Prurigo is a rare disease in this city amongst the children of the middle 
and upper classes, since we have seldom met with it. In Europe it is de- 
scribed as occurring in the children of the poor, though it is much less 
common than the eruptive diseases already treated of. Doubtless it occurs 
in this country also, but we have not found any original account of it in 
the works of American writers. 

Causes. — The only well-ascertained causes of the disease are the un- 
favorable hygienic conditions which exist amongst the destitute classes of 
society, — damp and ill-ventilated dwellings, unwholesome food, especially 
the use of salted meats and fish, and want of cleanliness as to person and 
clothes. 

Symptoms. — The papules of prurigo are small, but slightly prominent, 
and attended with moderate itching, constituting the prurigo mitis ; or 
they are larger, more projecting, and attended with the most violent pru- 
ritus, forming the prurigo fonnicans. The papules are usually of the 
color of the skin, except when they have been torn by the nails, and are 
generally seated upon the outer surfaces of the limbs, and the upper part 
of the trunk. 

When the itching is severe, the tearing of the papules by the nails 
causes the escape of a small drop of blood from the tops of many of them. 
The blood dries and forms so many small black crusts crowning the sum- 
mits of the papules, a peculiarity which constitutes one of the most dis- 
tinctive features of the disease. The papules terminate by absorption or 
by a slight desquamation. 

The duration of the eruption is very uncertain. In acute cases, when 
properly treated, it may end in a few weeks, though it often, and indeed 
more general^, lasts for several months. 

Diagnosis. — The only diseases with which prurigo is likely to be con- 
founded are strophulus or lichen. It may be distinguished, however, 
generally with ease, by the facts that the papules of prurigo are larger, 
less numerous, and more extended, than those of strophulus or lichen ; 
that in the latter diseases the papules are never crowned by the small 
black crusts of prurigo, and they are never attended with the same vio- 
lent itching as the former. 

Prognosis. — Prurigo is never perhaps a dangerous disease, though 
usually a very troublesome one from the severe irritation which attends 
it, from its not unfrequently obstinate resistance to treatment, and its 
disposition to relapse. 

Treatment. — The internal treatment of prurigo in children should 
consist in the use of sulphur, given alone or in combination with mag- 
nesia, of demulcent drinks, of mild laxatives when there is constipation, 
and of such remedies as may be rendered necessary by any disordered 
state of the digestive function. The diet must be carefully regulated. 



846 SQUAMA. 

It ought to be nourishing and sustaining, but at the same time light and 
easy of digestion. 

In addition to the internal treatment, simple warm-water baths, or 
emollient baths of flaxseed, bran, slippery-elm, or marsh-mallow, should 
be made use of in the early stage of the disorder. At a later period, 
alkaline baths, containing from three to eight ounces of carbonate of 
potash to each bath, according to the age, are recommended b}^ Cazenave 
and Schedel. To alla}^ the cutaneous irritation mild ointments are often 
found useful. Billard employed with success, in a child six months old, 
inunctions with the oil of sweet almonds. Soaps or lotions, containing 
juniper tar or carbolic acid, are excellent antipruriginous applications; 
and relief will frequently be obtained from the application of a dilute so- 
lution of chlorinated soda. When the case is obstinate, resisting emol- 
lient and alkaline baths, sulphurous baths must be made use of. 



CHAPTER VI. 

SQUAMA. 

The various forms of scaly disease, psoriasis, pityriasis, and ichthyosis, 
are so much more rare in children, and therefore so much less important 
practically, than the various eruptions we have thus far considered, that 
we deem it unnecessary, in a work limited in extent like this, to attempt 
a detailed account of them. We shall make merely a few observations 
on each, referring the reader, should he desire further information, to the 
special treatises upon diseases of the skin. 

Psoriasis is, in our experience, a very rare disease in children, though 
we have met with a few cases of it. It is met with in two forms, the 
psoriasis diffusa and guttata, of which the former is said to be the more 
frequent. 

Psoriasis diffusa appears in the form of patches of rather large, but 
very variable size, of irregular shape, and covered with thin scales of 
dried epidermis, which are constantly falling off and being renewed. 
When the scales are removed, the surface of the eruptive patch is seen 
to be of a dull red color, somewhat rough, and raised above the surround- 
ing skin. In severe cases, as the disease occasionally occurs in young- 
children, the skin presents numerous chaps and fissures, and is often ex- 
coriated more or less by the dress, or by the neighboring surfaces. From 
the excoriations is sometimes poured out an unhealthy secretion, which 
hardens and forms scabs. 

Psoriasis guttata appears in small, reddish, and rounded elevations, 
more elevated at the centre than the circumference, and of different sizes ; 
from that of the head of a pin, as mentioned by Billard, to that of a large 
pea, as seen by ourselves, and which become covered very soon after their 
appearance with fine, minute, and whitish scales. 



PITYRIASIS — ICHTHYOSIS. 847 

A third variety, psoriasis inveterata, a severe, obstinate, and inveterate 
disease, as met with in adults, is very rare, if not unknown, in children. 

Treatment. — In recent eases psoriasis is to be treated with simple 
warm water or emollient baths, and with mild liniments or ointments, 
such as oil of sweet almonds, glycerine alone, or glycerine mixed with 
cold cream or simple cerate. In more chronic cases the local treatment 
is the only one which promises any certain success. The particular mode 
of local treatment which we have found most successful is that recom- 
mended by Hebra, a short account of which will be found in our remarks 
on the treatment of chronic eczema. 

The carbolic acid soap, dilute citrine ointment, or weak solutions of 
caustic potash when there is much infiltration of the skin, are all service- 
able in the chronic form of the disease. 

In all cases the digestive function must be carefully attended to, any 
disorder that it may present being removed as rapidly and effectually as 
possible by the proper remedies. 

In cases where the eruption persists despite the use of local applica- 
tions and attention to the digestive functions, the child should be placed 
upon the use of the ferro-arsenical mixture. 

Pityriasis is a slight scaly disease, which may attack the head only, or 
extend to other parts of the bodj'. In children, however, it is generally 
confined to the scalp, and ma} T be recognized by the existence on the part 
of innumerable small, thin, whitish, furfuraceous scales, which form a 
thin or thicker covering for the scalp, in proportion to the amount of care 
bestowed on the cleansing of the head. The scales of epidermis are easily 
rubbed off, and the surface beneath is rarely found to present even the 
slightest inflammation. 

It is a disorder of minor importance, and seldom requires other treat- 
ment than some mild lotion or ointment, and strict cleanliness. When, 
however, it persists, the child should be placed upon the use of the ferro- 
arsenical mixture internal!^, and applications of dilute citrine ointment 
should be made to the patches of eruption. 

Ichthyosis is an eruptive disease inr which there appears on various 
parts, and usually over the larger portion, of the skin, epidermic patches 
or squamae, that are hard and dry, and of more or less considerable size. 
The patches are generally of a dirty gray or earthy color ; they exfoliate, 
and leave the skin beneath a little thickened and roughened, but never 
inflamed. The disease is unattended with either heat, pain, or itching. 
It is ordinarily congenital, lasts many years, and, according to MM. Caze- 
nave and Schedel, is incurable. * 

Billard recommends, however, in the ichthyosis of new-born children, 
the use of warm and emollient baths, frictions with oil of sweet almonds, 
or olive-oil, acidulated drinks, and perfect cleanliness. 



848 PARASITIC SKIN DISEASES. 

CHAPTER VII. 

DISEASES OF THE SKIN NOT CLASSIFIED AMONGST THE PRECEDING. 

SECTION I. 

PARASITIC SKIN DISEASES. 

General Remarks. — The diseases now regarded by many authorities 
as due to the presence of a vegetable parasite upon the skin are as fol- 
lows: 



1. Tinea Favosa or Favus, Parasite: Achorion Schoenleinii. 

2. Tinea Trico- f Tinea Tonsurans (Ringworm of scalp), -j 

, . -I Tinea Circinata (Ringworm of body), j- . . " " Tricophyton. 

I Tinea Sycosis (Ringworm of beard), J 

3. Tinea Versicolor (Chloasma, "Wilson), " Microsporon Furfur. 

4. Tinea Decalvans (Alopecia Areata), " Microsporon Audouini. 

There are several questions, however, in regard to these affections upon 
which doubts still exist, and which are of so much importance as to de- 
mand a brief examination. 

In the first place, it can scarcely be doubted by any one familiar with 
the use of the microscope, and who has taken the trouble to examine the 
subject, that parasitic fungi are found with remarkable constancy in 
the eruptions of these diseases. The opinion advanced by Wilson (Br. 
and For. Med.-Chir. Rev., 1864, and Diseases of the Skin, 7th Amer. ed., 
p. 614), that the structures found in these cases, are due to a peculiar 
"granular" degeneration of the normal elements of the part, owing to 
which they lose their power of developing into healthy epithelial struc- 
tures, but retain their power of proliferation, appears to us opposed to all 
sound reason and accurate observation. 

In addition, however, to the evidence furnished by the chemical and 
microscopical examination of the growths in question, their fungous 
nature is shown by the facts that they can be cultivated after removal 
from the bod} T , and that the diseases with which they are associated are 
contagious and can be communicated by inoculation to healthy persons, 
or even to some of the lower animals. 

In searching for these growths, the scrapings from the surface of the 
diseased spot, or the hairs which traverse it, ma}^ be taken for examina- 
tion; but, before subjecting them to microscopic study, they should be 
treated with dilute acetic acid to render them more translucent, and sub- 
sequently with a little sulphuric ether to remove the fatty granules which 
often obscure the fungus. 

The structures which the fungi affect are the hairs with their follicles, 
and the epidermis. 



GENERAL REMARKS. 849 

The special alterations which the hairs undergo will be detailed under 
the head of the different diseases ; the fungus gains entrance to the fol- 
licle, penetrates the bulb of the hair, insinuates itself between its longi- 
tudinal fibres, thus splitting it up and rendering it brittle. In the epi- 
dermis the fungus is said at first usually to appear beneath the superficial 
layer, until by its development it causes such irritation as leads to the 
exfoliation of this layer, when it reaches the surface and then multiplies 
rapidly. 

The objection which has been based upon this fact, that the growth 
cannot be a parasitic one, does not seem to us of much force, since it is 
easy to account for the introduction of such extremely minute bodies as 
the spores of these fungi beneath the superficial layer of the cuticle. 

Admitting then the presence of these parasitic growths, a more in- 
teresting question arises in regard to the relation which exists between 
them and the diseases with which they are associated ; whether, that is, 
the}' are essential to, and actually the causes of the respective diseases, or 
are merely accidental, and are present only because they find a suitable 
nidus for development in the diseased skim Opinions are at variance upon 
this question, but there are at least two considerations which render it 
probable that the fungi are essential rather than accidental productions. 
The first of these is, that the}' are present in the early stages of the dis- 
ease, before an}' considerable inflammatory change has occurred, and 
that in proportion as suppuration ensues they diminish in abundance. 
And, secondly, that, as already stated, they are capable of transmission to 
perfectly healthy persons by inoculation. 

There can, however, be no doubt that the development of the fungus, 
under ordinary circumstances, is greatly favored by the constitutional 
condition of the patient and the state of the cutaneous surface. Thus it 
is especially in children of a delicate or strumous constitution, that these 
various diseases are most frequently met with ; and when, in addition, 
personal filthiness with inattention to properly combing and cleansing 
the hair, and changing the clothing, are combined, the spores find the 
most favorable conditions possible for their rapid development. 

There remains the further question, upon which authorities are still 
divided, whether there are various fungi concerned in the production of 
these diseases, or whether the apparently different species are merely dif- 
ferent stages of a single fungus. For the sake of greater ease of reference 
and comparison we will here give a brief description of their character- 
istic appearances. 

Fungus of Favus. — In the earliest stage of development of the favus 
crust, it is still covered by the superficial layer of epidermis ; but later, 
when this is ruptured, it still presents an envelope of a sulphur-yellow color, 
which on microscopic examination shows a homogeneous or finely granular 
substance. The interior, of a pale white color, is the true favus matter, 
and consists of the sporules, thalli, and mycelia of a fungus named the 
achorion Schoenleinii, in honor of Schcenlein, who first fully described it. 

The sporules are of a rounded, or more frequently of an oval form, and 
have well-marked edges, and a homogeneous and slightly opalescent in- 

54 



850 PARASITIC SKIN DISEASES. 

terior. Their average diameter is about 3 ^ ^th of an inch. Many of these 
sporules are seen to be grouped together, while some are more elongated 
and present a contraction in the middle ; others are nearly triangular in 
form, with rounded angles ; others, 3-et more elongated, are marked with 
several contortions. Some sporules, completely formed, seem to have a 
double envelopment membrane, and others present in their interiors 
something like a nucleus. 

There are also present numerous diaphragmated tubes, formed by the 
development and confluence of the sporules, which are either simple or 
present ramifying branches. These tubes vary in diameter from 4 ou^th 
to T g J- oU th of an inch, and are either empt}^ or have granular contents. 
Amongst the sporules and mycelia, especially towards the circumference 
of the cups, may be seen a considerable number of molecular granules, 
which are probabty imperfect^ developed sporules. 

The next parasite, the tricophyton, is that which, according to McCall 
Anderson and some other dermatologists, produces tinea tonsurans, tinea 
circinata, and tinea sycosis. 

The microscopic characteristics of this parasite, as first described by 
Malmsten, in 1845, and since confirmed b}^ numerous observers, are very 
numerous rounded or oval sporules, about ^oo^ 1 mcn m diameter, which 
are isolated or united together into chains, and a comparatively small 
number of mycelial threads. 

Again, the parasite which by many observers is believed to cause tinea 
versicolor, is the microsporon furfur, discovered by Eichstadt in 1846. 
This fungus presents numerous rounded spores, and long tubes. The 
spores are about g^ooth inch in diameter, and are frequently collected 
together in large clusters, like bunches of grapes (Anderson). Some of 
the tubes observed are simple, and others jointed. 

In regard to the parasitic nature of alopecia areata, there is great 
doubt, and even so warm a supporter of the fungous origin of the other 
diseases we have mentioned as Dr. Anderson, does not allow it. 

Numerous observations have been made which go to show the existence 
of a very wide range of variation as regards form in these fungi ; and 
have led some observers to assert not only the identity of these particular 
forms, but indeed to refer all varieties of epiphytic fungi to some one 
central t} T pe. 

The evidence upon which this view rests, mainly drawn from the results 
obtained from germination of the various fungi, and from the study of 
their transitional forms, cannot at present be considered conclusive; and 
further investigation of the question is demanded. 

It is, however, thought 03^ some high authorities, that no doubt can be 
entertained in regard to the identity at least of the parasites which pro- 
duce the various forms of tinea, including the achorion of favus, the 
microsporon furfur of tinea versicolor, and the tricophyton of the various 
varieties of ringworm. The most complete exposition of the arguments 
upon which this view is based, will be found in Dr. Tilbury Fox's admi- 
rable treatise on skin diseases of parasitic origin (London, 1863). 

On the other hand, some eminent dermatologists believe that the fungi 



FAVUS. 851 

which produce these diseases, are essentially distinct. The arguments 
upon which the}' base this opinion ma} T be briefly expressed as follows, in 
the language of Dr. Anderson (Joe. cit., p. HO). 

That in all cases of successful inoculation with the achorion, tricophyton 
and microsporon furfur, the same parasitic disease has been produced as 
that from which the parasite was taken. That of the innumerable cases 
occurring in the human subject, illustrative of the contagious nature of 
favus, tinea tonsurans, and tinea versicolor, there is no authentic case in 
which one of these diseases gave rise to one of the others. 

That the difference in the appearance of the eruptions, when fully de- 
veloped, is so very striking as to lead to the belief that they are produced 
by separate parasites. , 

That there is no authentic record of the transition of one of these dis- 
eases into one of the others. 

That the microscopic differences between the three fungi are in many 
cases sufficient to base a correct diagnosis upon. 

That of the numerous instances on record of the transmission of tinea 
favosa, and tinea tricophytina, from the lower animals by contagion or in- 
oculation, favus has alwa3 r s given rise to favus, and tinea tricophytina to 
tinea tricophytina. 

We regard then the parasitic nature of these affections as undoubted, 
but more extended observation is necessary before the relations of their 
respective fungi can be determined. 



AETICLE I. 

FAVUS. 

Favus is a peculiar disease of the scalp, long confounded by different 
writers with other and very dissimilar affections of that part. In conse- 
quence of this confusion it has received a great variety of names, of which 
the most generally known are porrigo and tinea. In adopting the above 
title, we follow the example of Erasmus Wilson,, amongst the English, and 
of MM. Rilliet and Barthez, Gibert and Rayer, amongst the French. 

Definition ; Synonymes ; Varieties ; Frequency. — Favus is a spe- 
cific contagious eruption of the scalp, characterized by inflammation of 
the hair-follicles dependent upon the presence of a peculiar fungus, the 
achorion Schoenleinii. It is characterized at first by small 3^ellow pustules, 
countersunk in the skin ; these are soon converted into yellow cup-like 
crusts, which adhere often for a very long period. It usually causes per- 
manent loss of hair at the affected part. 

The disease is described by most of the English writers under the title 
of porrigo, but as several other eruptions have been included under the 
same name, we think it best to follow the example of Mr. E. Wilson, and 
call it favus. By MM. Biett and Cazenave it is designated, after Willan ? 



852 favus. 

jporrigo favosa and porrigo scutulata. MM. Ra}-er and Gibert, as above 
mentioned, give it the name of favus. 

There are two varieties of favus, the favus dispersus, the porrigo favosa 
of most writers, and the favus confertus, the porrigo scutulata of many 
observers. 

The disease is much less frequent than eczema of the scalp, but is 
nevertheless constantly met with amongst the crowded populations of 
Europe. In this country it is more rare, and amongst the middle and 
upper classes, at least of this city, is almost unknown, since we have 
never met with a case of it in our own practice, though we have occasion- 
ally seen it in the hospitals here. 

Causes. — The only well-ascertained exciting cause of favus is generally 
thought to be contagion, a quality of the disease acknowledged by most ob- 
servers, though denied by Mr. E. Wilson, who considers its cause a de- 
bility of nutritive vitality, allied with struma. It may be propagated by 
direct contact of the diseased with a healthy skin, or by means of combs, 
brushes, or other articles of the toilet ; and it is also probable that the 
spores may be carried by the atmosphere so as to communicate it by in- 
fection. It has been frequently propagated b} r direct inoculation, — by 
Remak, Bennett, Hebra, Bazin, Gruby, Kobner, &c. 

Favus is also said to be met with in the lower animals, and especially 
amongst mice and cats ; and cases are on record which render it highly 
probable that it may be communicated from them to the human subject. 

It occurs at all seasons, attacks either sex indifferently, and is met with 
at all ages, but is especially frequent in children and young people, and, 
indeed, when met with in adults, is usually found to have commenced in 
early life, and to have persisted for } T ears. Certain conditions act as pre- 
disposing causes in its production, and ma} r alone, perhaps, give rise to 
its development. These conditions are unhealthy hygienic influences, as 
unwholesome and insufficient food, poverty, filth, and the living in low, 
damp, and ill-ventilated dwellings. It is met with most frequently in 
persons of feeble, lymphatic, and especially in those of scrofulous con- 
stitution, though, be it remarked, it occurs also in persons of strong and 
vigorous health. 

Among those who believe in its truly parasitic nature, there are some, 
as Devergie, who believe that it may be spontaneously generated, the 
parasite originating in the body of the affected person. One of the facts 
upon w T hich this theory is based, is the asserted occasional cure of the 
disease b} T internal remedies, but we believe that these can only relieve 
it, by fortifying the system, and so removing the conditions which favored 
the development of the parasite. 

Symptoms. — Favus Dispersus, or Porrigo Favosa. This variety 
begins with very small pustules of a peculiar straw-yellow color, which 
exhibit from the first the special character of not being raised at all above 
the level of the skin. Directly after their formation, the yellowish matter 
which they contain begins to concrete, and there can be perceived from 
this early period a central depression in the crusts, which becomes more 
marked as these augment in size, so that at the end of five or six days 



SYMPTOMS. 853 

it is perfectly evident. Each pustule, and of course each crust is, as a 
general rule, traversed hy a hair. The favous crust is a very remarkable 
feature of the disease, and is in itself a pathognomonic symptom. As it 
increases in size, which it does gradually until it reaches in some in- 
stances a diameter of half an inch, the central depression above spoken 
of becomes more and more distinct, and the crust assumes, from this cir- 
cumstance, the shape of a cup with an inverted edge. This cup-like form, 
the peculiar straw-yellow color, and the fact that each crust is usually 
pierced by a hair, are the distinguishing characters of the disease. 

The pustules are usually isolated at first, though they may be arranged 
in groups of irregular size. When numerous, the crusts, by their gradual 
enlargement, touch at their edges, and blend into larger or smaller patches 
of irregular shape, but still presenting many little depressions correspond- 
ing to the first-formed pustules. In rare cases, the disease is so extensive 
as to form a kind of mask covering the whole scalp. 

When the disease is not interfered with by treatment, the crusts remain 
adherent for a long time, — for months or even years ; they become also 
paler in color than the}' were at first, and so dry and pulverulent, as to 
break very readily when rubbed or touched. They become, moreover, 
thicker and more massive, and lose their first regular cup-like form, from 
the disappearance of their depressions, and from the irregular and uneven 
shape given to their edges and surfaces, by the breaking which they 
undergo. When the case runs on in this way, the head exhales a most 
unpleasant odor, which has been compared to that of mice or the urine of 
a cat ; McCall Anderson has, however, noticed a very similar odor in cases 
of eczema impetiginoides of the scalp. In some instances, where the dis- 
ease is grossly neglected amongst the very poor, pediculi form in abun- 
dance amidst the crusts, and add to the disgusting appearance of the dis- 
order. 

When the crusts have been removed by any means, the surface of the 
scalp is seen to be red, moist, and to present slight erosions or even ulcera- 
tions. The crusts are reformed only by the eruption of new pustules. 

An invariable and unfortunate sequel to the favous disease is a more 
or less extensive loss of the hair. The hairs become loose from a very 
early period of the disease, and can be pulled out with great ease. As 
the case goes on they fall out, and the scalp is left smooth, shining, un- 
even, and deprived of hair. On these spots the hair seldom grows again, 
and if it does, it comes out thin, woolly, and with every appearance of 
weakness and unhealthfulness. 

Though the usual and favorite seat of favus is the scalp, it is met with 
occasionally on the forehead, temples, chin, and eyebrows, and, in still 
rarer instances, on the shoulders, elbows, forearms, on the upper and 
outer parts of the legs and thighs, on the scrotum, and even on the nails. 
Even in such cases, however, it has generally existed first on the scalp, 
and extended thence to the other parts, though it may sometimes begin 
upon the trunk or limbs in consequence of a direct application to them 
of the contagious element. 

Favus Confertus, or Porrigo Scutulata. — In this variety of favus 



854 favus. 

the pustules are arranged so as to form circles or rings upon the forehead 
or scalp, instead of being dispersed irregularly over the scalp, as in the 
preceding variety. The disease begins with red, circular patches, at- 
tended with a good deal of itching, upon which, after a short time, appear 
small 3 T ellow pustules, that seem to be sunken in the skin. The pustules 
are more numerous on the circumference than at the centre of the red 
patch or disk; or the latter increases in size by the extension of the dis- 
ease to the follicles just bej-ond its outer edge. The pustules are exactly 
like those of favus dispersus, except that their yellow color is of a lighter 
tint. They desiccate very rapidly, and form crusts which are very thin 
at first, never very thick, and of an irregular shape. 

When the disks are very numerous, either originally, or hj propaga- 
tion of the disease from part to part, they meet at their borders, blend 
together, and give to the scalp the appearance of an extensive and irregu- 
lar crust, presenting at its circumference curved lines, marking the seg- 
ments of circles of which the whole is composed. The crust has some- 
times covered the whole scalp, excepting merely a small border at its 
circumference, where ma}^ still exist some scanty remains of the hair. 

When the crusts are removed the surface beneath is found to be red 
and tumid, according to Wilson, and to present numerous } T ellow points. 
Cazenave and Schedel state that when the crusts fall, they leave exposed 
a large, uneven, furfuraceous patch, upon which new favous pustules do 
not appear for a long time often. The hair is in great measure destroyed 
over the diseased surfaces, though not so completely, it is said, as in the 
other variety. 

Favus is not, in either variety, attended with constitutional sjinptoms. 
The only marked local symptom complained of is the itching, which is 
alwaj'S greatly aggravated by want of cleanliness. 

Nature of Favus. — We have already, in our general remarks intro- 
ductory to this class of skin diseases, given the arguments which prove 
their parasitic nature. 

Mr. E. Wilson, alone among dermatologists of note, persists in regard- 
ing favus and the others, as mere alterations in the nutrition of the skin 
dependent upon constitutional nutritive debility; and he refers the char- 
acteristic fungous elements revealed by microscopic examination, merely 
to a peculiar granular degeneration of the epithelial elements. 

We refer the reader, for a more full discussion of this question, to 
the works already quoted, merely adding here that, in our opinion, the 
results of microscopic examination, the results of inoculation of the 
parasite in man, as well as in the lower animals and plants, the undoubt- 
edly contagious nature of the disease, and finally the astonishing and 
never-failing success of the local treatment when properly carried out, 
conclusively show its parasitic nature. The reader is also referred to 
the remarks introductory to this chapter for a full description of the 
parasite, the achorion Schoenleinii, which is the essential cause of favus ; 
as well as for the differences which distinguish it from the parasites 
which are found in the various forms of tinea. 

Diagnosis. — The diagnosis of favus rarely presents any difficulties. 



DIAGNOSIS — PROGNOSIS — TREATMENT. 855 

The peculiar pustules which exist at first — small, yellow, on a level with 
or below the surface of the scalp, and the crusts which so soon follow 
these, saffron-yellow in color, dry, and cup-shaped, will mark a case of 
favus dispersus from every other disease. In favus confertus the same 
characters exist, but the crusts and pustules are arranged on circular 
erythematous disks, instead of being isolated or dispersed as in favus 
dispersus. 

From impetigo of the scalp, which is the only disease with which it is 
at all probable that it would be confounded, it may readily be distin- 
guished by an examination of the primary characters of the two disorders. 
This primary character can always be found by searching at the outer 
edges of the diseased surface. In favus the pustule is small, depressed, 
and contains very little fluid, while in impetigo it is large, globular, and 
projecting. The crusts are very different: in the former dry, as though 
dusted with sulphur, cup-shaped, depressed, aud usually traversed by a 
hair ; in the latter, rugous, irregular in shape, not cupped, resting above 
the skin, and generally somewhat moist and soft. The microscopic ex- 
amination of the hair or crusts in favus also shows the presence of the 
achorion Schoenleinii, which is never met with in impetigo. Lastly, the 
alopecia which so constantly results from favus, does not occur in im- 
petigo. 

Prognosis. — Favus is a serious disease because of its usually long dura- 
tion, the difficulty often experienced in effecting its cure, and because of 
the loss of hair which it occasions. 

Treatment. — The treatment of favus should be both general and local, 
for though some writers, and particularly Cazenave and Schedel, state 
that it must be altogether external, and that in spite of numerous trials 
the} T do not feel authorized to propose any internal means (Malad. cle la 
Peau, 4eme eel., p. 326); others, as Wilson, Bennett, and Neligan, recom- 
mend constitutional remedies as of very great importance in assisting the 
cure. 

The general treatment must be such as may seem called for by the 
state of health of the individual patient. Wheu, as so often happens, the 
disease occurs in a scrofulous person, cod-liver oil, iodide of potassium, 
nourishing food, air, and exercise, are of the utmost importance. When 
the health of the patient is feeble and broken from the want of wholesome 
and abundant food, from insufficient clothing, or from residence in a 
vitiated, close, and confined air, the removal of these conditions, which 
undoubtedly act as predisposing causes in the production of the disease, 
cannot but aid in its cure. Dr. Neligan (Dublin Quart. Journ. of Med. 
Sci., vol. vi, p. 56) recommends very highly the use of the iodide of 
arsenic as a constitutional remedy. He states that it may be given with 
the greatest safety to the youngest child, "its effects being, of course, 
duly watched." The dose for a child six years old is one-fifteenth of a 
grain, and, for a younger one, from one-eighteenth to one-twentieth of a 
grain, three times a day. Dr. Neligan speaks, however (loc. c?7., p. 62), 
of substituting the yellow iodide of mercury for the iodide of arsenic in 
the case of a child three years and a half old, being afraid to give the 



856 favus. 

latter to so young a child. He nevertheless gave this remedy afterwards 
in the case referred to, but in the dose only of the twenty-fourth of a 
grain every morning. It is given to children in the state of powder 
mixed with sugar or aromatic powder, and produces, when the sj^stem is 
saturated with it, some constitutional symptoms, as acute headache, dry- 
ness of the throat, &c. He has given it, however, in some cases, in full 
doses for several weeks without any manifestation of its effects, further 
than those produced upon the disease. When it does give rise to con- 
stitutional symptoms its v use is to be intermitted for some days, and an 
active purgative administered. 

The local treatment of favus is undoubtedly that upon which we must 
chiefty rely, since the essential element in the treatment must always be 
the destruction of the parasite. 

The mere application of remedies adapted for this purpose, called para- 
siticides, is, however, rarely of itself sufficient, since they cannot pene- 
trate to the hair follicles, and it is, therefore, directed by most authors 
of experience in the treatment of this disease that the hairs must be re- 
moved from the affected parts before the application can' be efficiently and 
successfully made. Before doing this the crusts must be removed. Some 
recommend for this purpose poultices, but these are condemned by Wilson, 
as clumsy, and by Lebert as causing the extension of the disease by the 
softened sporules which spread to the surrounding surfaces and propagate 
the disorder. This objection does not, however, appear valid, and their 
use is countenanced by many good authorities. Wilson recommends their 
removal by means of a local vapor-bath, applied through the medium of a 
caoutchouc cap, or, if this is not at hand, by laying a piece of folded lint, 
wetted in a solution of subcarbonate of soda or potash, upon the head, 
and covering it with an oiled silk or gum elastic cap, which should include 
the entire scalp. M. Lebert insists upon the necessity of removing the 
favi (not the pustular crusts which accompan}^ the specific vegetable 
growth), in their dry state, by means of small spatulas, needles, or some 
kind of instrument. The epidermis is readily detached from around the 
favus, and this latter, which adheres but slightly to the skin, is then easily 
removed. M. Lebert states that this is so easily done, that he has been 
able to teach his ward-attendants to remove them without pain to the 
patients. Hebra uses applications of alcohol which cause the crusts to 
shrink and thus lose their attachments, when they are readily removed. 

After the crusts have been gotten rid of, the scalp should be well washed 
with soap and water in order to remove any favous sporules that may 
have escaped and become free, and the hair should then be cut short. 
Yarious applications are then recommended, before proceeding to epila- 
tion, as tending to allay the irritability of the scalp and to render the hair 
less friable; among these are oil of cade (Bazin) and almond-oil (Ander- 
son) which maybe applied for a fewdaj^s before epilation is begun. There 
are various methods which have been adopted for the extraction, but the 
best is undoubtedly to employ a small pair of forceps with square ends, 
and fine but not sharp teeth, so as to enable the operator to catch the 
delicate and brittle hairs surety without breaking them. The hairs must 



TREATMENT. 857 

be extracted singly, and so soon as a little space has been cleaned, the 
parasiticide remedy should be applied so as to secure its entrance to the 
follicle. A single epilation is frequently not sufficient, but it is easy to 
distinguish, by the appearance of the surface and the growing hairs, those 
parts where the disease has been eradicated. This process is at first 
somewhat tedious both to operator and patient, but by practice a degree 
of skill is acquired which enables the physician or trained nurse to remove 
the hair rapidly and with very little discomfort to the patient. 

As soon as a clean surface has been thus obtained, some application in- 
tended to destroy the vitality of the vegetable growth ought to be made 
use of. One of the best for this purpose is a solution of corrosive sublimate, 
the strength of which, according to Lebert, ought to be, when employed 
in lotion, from two to four grains to the ounce, and, when used as a fomen- 
tation, weaker. This is also McCall Anderson's favorite application. Dr. 
Bennett (Banking's Half-Yearly Abstract, No. xii, 1850, Am. ed., p. 73), 
employs, to fulfil this indication, cod-liver oil. The head is kept con- 
stantly smeared with the oil, and covered with an oiled silk cap. This 
application is, however, merely palliative, and, so soon as it is intermitted, 
the disease reappears. 

There are various other remedies that have been applied to the diseased 
scalp empirically, either to " modify the state of the skin," to " excite the 
disordered follicles to healthy action," or, lastly, to " destro} r the vitality 
of the fungus, and, by altering the nature of the soil on which it flour- 
ished, to prevent its reproduction." Without attempting to define the 
mode in which any of these various substances may produce their effect, 
we deem it best to mention as succinctly as possible those which have the 
strongest testimony in their favor. 

Mr. E. Wilson, who it will be remembered does not believe in its para- 
sitic nature, is less favorable to strong applications than he was formerly. 
Those he now prefers are the ceratum tiglii, containing from ten to thirty 
drops of the oil to the ounce ; the unguentum hydrargyri nitratis, diluted 
one-half; the unguentum hydrargjTi nitrico-oxidi, diluted in similar pro- 
portion ; the compound sulphur ointment, and some others. 

Dr. Bennett's application of cod-liver oil has been referred to above. 
This, in connection with the constitutional treatment for scrofula, is said 
to have cured, on an average, in six weeks. 

MM. Cazenave and Schedel recommend alkaline and sulphurous appli- 
cations, and acidulated lotions. They speak very favorably of, and give 
much the highest place, amongst the substances to be used in friction, to 
the iodide of sulphur. This remedy was originally made use of by Biett, 
and employed by him with much success. Its efficacy is attested also bjr 
Lebert. It is used in the form of an ointment, consisting of from a scruple 
to half a drachm of the drug to an ounce of lard, and is to be applied 
morning and evening to the diseased surfaces by gentle friction. 

Applications of hyposulphite of soda, in proportion of 5j to fgj of 
water, or of sulphurous acid lotions, are highly recommended. Among 
the parasiticides most valued in France, are oil of cade and turpeth min- 



858 TINEA. 

eral, which latter ma} 7 be employed in the proportion of £j to f gj of gly- 
cerine of starch, which is perhaps the best excipient for the various para- 
siticides. 

Ointments and lotions containing carbolic acid have been much em- 
phyyed of late, but apparently not with entire success. 

Dr. Fuller recommends the ablution of the head twice a day by means 
of soft soap, and the inunction of an application composed of equal parts 
of unguentum hydrargyri ammonio-chloridi, and unguentum picis liquids. 
He states that a cure may usually be effected by this plan in from two to 
four weeks. 

Under any plan of treatment, a complete cure is rarely obtained in less 
than from four to eighteen weeks ; the disease is extremely obstinate, and 
there is a strong tendency to the redevelopment of the parasite after the 
cessation of the local treatment, until it be completely eradicated. By 
persevering in the plan above recommended, however, this can invariably 
be effected, and a perfect cure obtained, with the exception of patches 
of baldness, which but too frequently- follow, from the destruction of the 
hair follicles. 



AKTICLE II. 

TINEA. 

"We have already, in our general remarks introductory to this chapter, 
stated our belief that the various forms of tinea or ringworm are con- 
tagious diseases, and due to the presence of a peculiar fungus, the trico- 
phyton. 

The ordinary varieties of tinea which are described, are tinea tonsurans, 
or ringworm of the scalp ; tinea circinata, or ringworm of the general 
surface ; and tinea sycosis, or ringworm of the beard. With the latter 
form, of course, we are not at present concerned, nor are its relations to 
the two other varieties indisputable, since opinions are still divided as to 
its contagious and parasitic nature. 

There is, however, abundant reason for believing the essential identity 
of tinea tonsurans and tinea circinata. In addition to the results of 
microscopic examination, which reveals the presence of the same fungus 
in both, there is the strongest clinical testimony to the same effect. Thus 
it constantly happens that patches of the two varieties will be observed 
upon the same patient, and there are innumerable instances on record to 
prove that they give rise to each other. 

These diseases have been described by some authors under the generic 
name of porrigo ; by others under that of herpes. Wilson, in his last 
edition, employs the term trichinosis to designate the group. 

Causes. — The peculiar parasite is the essential cause of the disease ; 
and the mode of its propagation is chiefly by contagion. Mr. Wilson be- 
lieves the cause of the disease to be imperfect nutrition ; but it is quite 
certain that the only way in which a scrofulous or debilitated constitu- 



SYMPTOMS. 859 

tion can influence the production of the disease, is by favoring the more 
ready growth of the parasite. In like manner, dirtiness of every kind 
may be said to be a predisposing cause. 

The influence of these is, however, trifling, and we have frequently 
met with the disease among families living in easy or very affluent cir- 
cumstances, the children of which were perfectly well lodged, well clothed, 
and well fed, and to whom eveiy attention required by the nicest clean- 
liness was given. The means b} T which the affection is communicated are 
such as brushes, combs, caps, &c, or by the direct contact of the dis- 
eased surfaces. 

One of us has but lately had an opportunity of studying, on a large scale, 
these affections and the mode of their transmission, at a large Children's 
Home in this city. There were a considerable number of children, about 
twenty in all, affected with the disease in a severe form ; by strict isola- 
tion, by the utmost care in preventing any use of their combs, brushes, 
caps, or clothing, by the other children, by covering the entire scalp with 
an oiled silk cap, whenever the} T mingled with their comrades, the disease 
was prevented from spreading. It was, however, frequently observed, that 
in the children who suffered with tinea tonsurans of the scalp, patches of 
tinea circinata would appear either on the neck or face, or on some part 
which co aid be brought in contact with the affected surface ; and its 
highly contagious nature was unhesitatingly believed by all the atten- 
dants, who had indeed themselves furnished the strongest evidence pos- 
sible of it, by each and all contracting the disease repeatedly from hand- 
ling the children in dressing them, or in making applications to the 
affected parts. 

Age exercises a marked influence upon the production of these diseases, 
tinea tonsurans being confined to childhood and early youth, most com- 
monly occurring between the ages of three and twelve years ; though 
tinea circinata may be met with at any age. 

Tinea Tonsurans — Symptoms. — Those who regard this disease as a 
variety of herpes, describe its first appearance as a ring of minute ves- 
icles ; this, however, is not essential, and the disease most frequently 
begins with little eiwthematous patches which increase circumferentially 
while they heal in the centre, leaving the skin more or less furfuraceous. 
When fully established, the disease appears in the form of furfuraceous 
patches of oval or circular shape, which are at first not more than ^th or 
ith of an inch in size, but which increase gradually until they attain a 
diameter of one or two inches, and seldom more. The diseased surface 
is slightly thickened, elevated, of a grayish, bluish, or slate color, and 
covered with fine dry scales, which are very easily rubbed off, and quickly 
renewed after being removed by any cause. 

The hairs are altered from the very first. In the early stage the aper- 
tures of the follicles of the diseased hairs are generally more or less 
prominent or papillated, and the hairs are unnaturally brittle, dull, 
and dry, and are bent on themselves and twisted, so as not to lie 
smooth, and the roots are somewhat matted together by the furfuraceous 
scales. A little later, the} 7 break off at a short distance from the diseased 



860 TINEA CIRCINATA. 

surface, leaving the circular patches partially deprived of hair. The 
broken hairs are uneven in length, and otherwise altered in appearance, 
being bent and twisted, and having become lighter in color than the 
original hairs, so as to assume somewhat the look of bundles of tow. The 
enlarged follicles also dot the surface, giving it the appearance of cutis 
anserina, or the skin of a plucked fowl. The epidermis and the stumps 
of the broken hairs now become covered with a characteristic gra} T ish- 
white powder, consisting of the sporules of the tricophyton, the peculiar 
parasite ; and, on examining the hairs, the same fungus will be found 
penetrating into the bulbs and shafts between the separated fibres, and 
causing here and there, by its accumulation, swellings or bulgings of the 
shaft. 

The disease is unattended by any local sensations, excepting a mode- 
rate degree of itching. 

If the disease persist and the degree of inflammation increases, there 
may be a good deal of infiltration of the scalp, and the surface becomes 
tumid, and dotted with enlarged orifices of hair follicles, or there may be 
an eruption of vesicles or pustules, which dry aud form scaly, 3 T ellowish 
crusts. 

Diagnosis. — This disease is easily distinguished from other eruptions of 
the scalp. The appearances it presents when fully developed, are utterly 
unlike those of favus or eczema impetiginocles capitis. In favus, the pe- 
culiar cup-shaped crusts and the presence of the spores of the achorion, 
are sufficient to prevent mistakes ; while in eczema, the eruption is sero- 
pustular, with the formation of 3-ellowish or brownish yellow crusts ; the 
patches are not circular, the hairs are healthy, the itching is extreme, 
and finally the disease is not contagious ; in all of which particulars it 
differs entirely from the eruption of ringworm. 

Phrvriasis capitis does not occur in circular patches, but affects the 
whole scalp ; it is not parasitic nor contagious, and does not lead to so 
much alteration of the hairs. 

Occasionally tinea tonsurans, either from the irritation of scratching, 
or some other cause, may be associated with eczema impetiginodes, which 
to a great extent obscures the former disease, though a careful search 
will usually detect some of the characteristic broken stumps of hairs, 
loaded with the parasitic growth. 

Prognosis. — Ringworm of the scalp is entirely devoid of danger, but 
is an exceedingly troublesome disease, as it is apt to spread to other 
children, and is often very difficult of cure. Its duration is very indefi- 
nite, and it not rarely leads to patches of permanent baldness. 

Tinea circinata, as we have already said, frequently occurs in connec- 
tion with tinea tonsurans, appearing on the neck or face ; though it occurs 
also as an independent disease on any part of the body, and in patients 
of every age. 

It begins as a little rose-colored, slightly elevated spot, which soon be- 
comes the seat of slight furfuraceous desquamation ; and extends circum- 
ferentially, healing in the centre, until it forms a large slightly elevated 
erythematous ring, inclosing a portion of sound skin. 



TREATMENT. 861 

In other cases, minute vesicles form on the reddened inflamed ring. 
They follow the usual course of development, being at first transparent, 
then turbid, and finally drying into small thin scales. 

The size of the patch varies greatly, being in some instances small, not 
larger than a shilling, and in others presenting a diameter of two or three 
inches. When small, the redness covers the whole of the patch, but is 
much fainter in the centre than at the circumference ; when large, the 
centre regains the natural color of the skin. Usually the ring is exactly 
circular, but at times it assumes an oval shape. 

If any hairs have been growing on the affected spot, they become 
brittle and changed, as before described. There are usually several such 
circles present, and in some cases they are formed in great numbers. 
The only symptoms accompanying the eruption are slight pricking, 
smarting, and itching in the part. 

Diagnosis. — There are but few diseases with which there is any danger 
of confounding tinea circinata. It is distinguished from erythema circi- 
natum by the greater elevation of the marginal ring, by the presence of 
the parasite, and by its contagious nature ; and the two last peculiarities 
serve to distinguish it from psoriasis circinata. 

According to McCall Anderson, and some other dermatologists, herpes 
iris is merely a form of this affection. 

Treatment. — The cases of tinea tonsurans that have come under our 
charge, have proved in many instances very rebellious to treatment. 

Strict attention should always be paid to cleanliness and hygienic 
rules ; and, if the disease be associated with any impairment of the consti- 
tution, cod-liver oil, iron, in the form of the syrup of the iodide in syrup 
of sarsaparilla, arsenic, and bitter tonics should be administered. 

The local treatment is, however, the most essential. Where the dis- 
ease occurs on a part covered with hair, epilation is advised by some 
authorities, and it would in all probability facilitate and hasten the cure. 

Among the local applications which have proved most useful to us have 
been sulphuro-alkaline lotions, composed of 3J of subcarbonate of potash 
and 3U of sulphur, to a pint of water, applied by washing with a sponge 
several times a day; strong solutions of sulphite of soda; and an ointment 
consisting of 3j of muriate of ammonia, mixed in an ounce of sulphur 
ointment, applied first at night by inunction, and after a time on rags. 

Alkaline remedies have also been much used by other observers, who 
recommend washing the scalp every morning with a lotion composed of 
gr. xxx or xl of carbonate of potassa or borax to a pint of water, and apply- 
ing in the evening an ointment containing 9j of tannic acid to ^ j of lard. 

Much more stimulating applications are, however, highly recommended, 
and often prove very serviceable. Thus Mr. Wilson advises a single ap- 
plication of the acetum cantharidis, or the stronger acetic acid ; and De- 
vergie recommends a solution of nitrate of silver, 3j to f £j of water. 

Various mercurial applications are also advised, as solutions of corrosive 
sublimate, the citrine ointment, or the following, recommended by Jenner : 

R. — Hydrargyri Ammonio-Chloridi, . * . gr. xx. 
Ung. Sulphuris, 5jiv. 



862 TINEA. 

Tarry applications may also be employed in obstinate cases, in the form 
of lotions, ointments, or soaps, containing tar, or oil of cade. 

Nayler speaks highly of a plan used by Mr. Coster, who saturates the 
part with the following mixture : 

&.— Iodini, £ij. 

01. Picis, fgj. 

This solution is to be rubbed in firmly with a piece of sponge on the end 
of a piece of wood or whalebone. It is allowed to dry on the part, and 
left until the cuticle and the black crust separate at the end of a week or 
ten days. 

In cases where many patches are present over the body, it is advisable 
to emplo}" mercurial or sulphur vapor baths. 

It must not, however, be forgotten that these varieties of tinea are 
among the most obstinate disorders to which children are subject. The 
most faithful trial may be made with the remedies recommended above, 
for a long time, without success, and it is often necessary to persevere in 
their use for months ; conjoining the treatment with a change of diet, 
and, when possible, with a change of residence, before the affection will 
be entirely and permanently cured. 

Cases. — The following cases may be taken as types of the aggravated 
form of tinea, after it has persisted a long time and become complicated 
with secondaiy eruptions of eczema or pityriasis. It will be noticed that 
in the following records, all of the patients are stated to have been mark- 
edly scrofulous ; but this circumstance must not have too much impor- 
tance attached to it, since in the Home where these cases occurred, almost 
eveiy one of the children presented unquestionable marks of the strumous 
diathesis. There can be no doubt, however, that this condition of con- 
stitution strongly favored the development of the disease, rendered it 
more severe and obstinate, and also favored the occurrence of the secon- 
daiy inflammatory eruptions. 

George T., set. five, scrofulous, admitted to Home in 1864, with bleed- 
ing piles. Tinea tonsurans appeared two months after admission, and 
persisted with various fluctuations for eighteen months, when it became 
complicated with eczema impetiginodes. Applications of tar and corro- 
sive sublimate have been chiefly relied on. 

£s"ov. 30th, 1866. Scalp covered with graj^ishyellow crusts, one-fourth 
inch thick, in places running together or forming isolated lumps. A few 
spots of tinea circinata on face and neck. The scalp is reddish, and 
there is very little discharge from it. The hairs are sparse and broken. 
The cervical glands are much enlarged on both sides. On removing the 
crusts and examining the base, numerous exudation corpuscles, and some 
spores of tricophyton were found; the epithelium not very granular. 

Poulticed to remove the crusts. Ordered iodide of iron and potas- 
sium internally. 

Dec. 4th. Scalp quite clean from crusts, but remains reddish, with here 
and there bald patches. Numerous spores of tricophyton found in the 
hairs and among the epidermic cells. 



CASES — TREATMENT. 863 

Solution of soda? sulphis (£j to Oss water), applied morning and even- 
ing, and kept on during the whole time by means of folds of linen satu- 
rated in the solution, and covered with an oil-silk cap. 

Dec. 16th. Much improved. Scalp cleaner, and less red. Some flat, 
thin, whitish scales over surface. Hairs more free from tricoplryton, but 
numerous spores can still be seen by scraping moist surface beneath the 
thin crusts. 

Treatment continued, with ultimate success. 

William L., aet. 5 ; hereditary tendency to tuberculosis ; scrofulous ; 
cervical glands enlarged on both sides; admitted in 1865, and has had 
tinea ever since, man}* forms of treatment having been tried, but none 
with more than temporary success. 

November 30th, 1866. The scalp is reddened, and wax-like from infil- 
tration, with patches of baldness. In places where the eruption is oldest 
it is covered with whitish scales ; elsewhere, there are scattered or 
confluent grayish-yellow or yellow crusts. Discharge of pale, thin, fetid 
pus. 

On examining the surface beneath the crusts, numerous pus cells, and 
spores of trieophyton, often aggregated together, are found. The hairs 
have lost their normal appearance entirely, are bent, and where they 
emerge from the scalp, the shaft is swollen, with bulging outline. The 
shafts are covered with spores of trichophyton, and their longitudinal 
fibres separated by collections of the fungus. Some of the bulbs remain 
healthy, others are broken and apparently converted into masses of fun- 
gous spores. 

Ordered poultices to remove crusts ; iodide of iron and potassium in- 
ternally. 

December 4th. Scalp clean, with exception of minute white scales; 
shows bald glazed patches, with light, short, thin hairs. Ordered same ap- 
plication of sulphite of soda. 

December 15th. Immensely improved; the large bald patches still 
covered with minute shining white scales, but few tricoplryta to be seen. 

Charles L., set. 4, admitted in Ma} T , 1866 ; hereditary tendency to tu- 
berculosis ; cervical glands slightly enlarged. Tinea soon appeared on 
the face and scalp, and in early part of November, thin flat grayish-yel- 
low crusts formed over vertex, the rest of the scalp being covered with 
minute whitish scales. 

November 30th, 1866. Ordered poultice to remove crusts; iodide of 
iron and potassium internally. 

December 4th. Scalp comparatively clean. Patches of baldness, es- 
pecially over parietal protuberances, with straggling, short, light-colored 
hairs. Abundant spores of trieophyton found. The hair-shafts much in- 
volved, collections of the parasite existing between the longitudinal fibres. 
The bulbs are also diseased, and seem to have become aifected just below 
the exit of the hair ; the bulb first becoming swollen at this point and 
then its sheath having become destro} T ed, so that the fungus forms a bed 
surrounding the shaft. 

Ordered same application of solution of sulphite of soda. 



864 ALOPECIA AREATA. 

December 16th. Yery much improved; scalp smooth and clean, ex- 
cepting above the ears, where there is on each side a collection of thin 
yellowish crusts. The hairs passing through these had numerous pus 
cells adherent to their shafts, but the hair bulbs seemed healthy, and no 
spores of tricoplryton could be found on any of them. 



AKTICLE III. 

ALOPECIA AREATA. 

This affection, which is also known by the names of area and tinea 
decalvans, is characterized by the loss of hair in circumscribed patches 
of round or oval shape. It is by no means a rare disease, and is much 
more common in children than in adults ; thus of 42 cases cited by Hut- 
chinson, 28 were under fifteen, 14 above that age. 

Cause. — There is still much doubt as to the essential cause and nature 
of alopecia areata. 

Grub}^ is said to have discovered in 1843 a fungus in it, which has been 
called the microsporon audouini, and some dermatologists of high au- 
thority, accept its parasitic nature" It cannot, however, be said to be 
demonstrated, since the parasite is very rarely found ; so that Ander- 
son, who has made numerous microscopic examinations, has never suc- 
ceeded in detecting it. 

Wilson considers it as due to suspended innervation, as a kind of pare- 
sis of innervation. 

The disease appears to be, at least in some instances, propagated by 
contagion ; though it certainly possesses this property to a much less de- 
gree than either of the forms of ringworm. 

Symptoms. — The disease is limited to the scalp in children ; though in 
adults it may attack any hairy part. In some cases, the first intimation 
of the existence of the disease is the sudden discovery of a bald spot, but. 
in others, though less frequently, there is slight itching, with redness and 
branny desquamation of the affected spots. 

The bulbs of the hairs then atrophjr, and become tapering instead of 
being rounded and club-shaped ; the hairs themselves become dry, lustre- 
less, and brittle, with a fibrous fracture, and rapidly fall out, leaving bald 
patches. 

These patches vary in size from one-half inch to an inch or even more 
in diameter, and there may be but a single one present, or they may be 
numerous, in which case they often coalesce, forming large patches of 
irregular shape ; when the patches are single they usually assume a round 
or oval form. 

The denuded portion of scalp is peculiar in appearance, being very 
white and polished, and thinner than the surrounding healthy scalp ; the 
sensibility of the affected surface is also frequently impaired. 

Diagnosis. — There can be no difficulty in recognizing the fully devel- 



SCLEREMA. 865 

oped disease, excepting in the comparatively rare cases when it is com- 
bined with other skin diseases, as eczema or pityriasis. 

Prognosis. — The only danger attendant upon alopecia areata is that 
of deformity, which is, in some cases, very great, depending of course 
upon the extent of the disease and the stage at which it is brought under 
treatment. 

If the patches are small, the scalp not materially atrophied, and the 
orifices of hair follicles still visible on the bald patches, there is good 
reason to hope that steady persistence in treatment will effect a cure. 

Treatment. — Those who regard this as a parasitic affection, advise the 
ablation of the hairs immediately surrounding the patch, and the applica- 
tion of some of the stimulating parasiticides recommended in the article 
on tinea. 

The majority of authors, however, content themselves with the applica- 
tion merely of such stimulating lotions and ointments as will increase the 
nutrition of the affected spots, and favor the renewed growth of hair. 

Among the ointments which are most highly recommended, are those 
containing the red iodide, the nitrate, the ammonio-chloride of mercury ; 
some form of sulphur ; or tar, iodine, or cantharides. 

Hillier recommends, as the treatment he has found most useful, the ap- 
plication at long intervals of acetum cantharidis to the bald patches ; 
painting them every other day with tinct. iodine, washing the head twice 
a week with soap and cold water, and applying a wash (consisting of one 
pint of rum, one ounce of tinct. cantharidis, one-half ounce of spirit, am- 
nionic aromat., and ten ounces of water) to the parts of the head which are 
not bald, twice a week. 

The effect of this local treatment w T ill be much increased by the internal 
administration of arsenic and iron. 



SECTION II. 
ARTICLE I. 

SCLEREMA. 

Definition; Synonymes; Cause; Frequency. — This peculiar affec- 
tion, characterized by induration of the skin and subcutaneous tissue, 
with or without oedema, has been described by numerous writers, almost 
each one of whom has given a distinct name and theory for the disease.. 
Among these names the most appropriate are sclerema, scleriasis, sclero- 
derma, induration of the cellular tissue, or chorionitis. 

It is an affection not altogether peculiar to infants, though it is rare to 
find it well developed after the first few months of life. There are, how- 
ever, a sufficient number of cases in adults on record to establish the fact 
of its occasional occurrence at all ages. It must be a very rare disease 

55 



SCLEREMA. 

in this country even among infants, and especially in private practice, as 
we have met with but two well-marked cases in adults, and but one in- 
stance occurring in childhood, which was the case in which imperfect 
induration of the skin was developed in connection with atelectasis pul- 
monum, to which allusion is made in our article upon this latter affection. 

In the large foundling hospitals in Europe, however, where so many 
causes exist to depress the vitality of the infants, it is of very frequent 
occurrence. Under such circumstances, moreover, it generally develops 
itself within the first twelve or fourteen days after birth. 

The most varied causes were formerly assigned for this disease, before 
the researches of Bailly and Legenclre appeared to point out sclerema as 
one of the results of imperfect expansion of the lungs. As we have already 
remarked, it is seldom observed among the children of the upper classes 
of society, so that all those conditions which depress the strength of the 
child, as insufficient or unhealthy nourishment, imperfect clothing, cold, 
especially when associated with moisture, ma} 7 be considered as the pre- 
disposing causes of sclerema. The influence of dampness and cold in 
developing this affection is shown by the fact, deduced from numerous 
statistics, that twice as niaivy children are attacked during the cold and 
w r et months of the year as at other times, although there are cases re- 
corded as occurring in the hottest months. 

Aiithors still differ in regard to the relation between atelectasis and 
sclerema. West 1 accepts the results of the researches of Bailly and Legen- 
dre, and considers it a result of the imperfect expansion of the lungs. 
Bouchut, 2 on the other hand, regards the changes found in the lungs as 
the result rather than the cause of the induration of the skin. 

Letourneau 3 agrees with West in regarding sclerema as a condition de- 
pending primarily on congenital weakness, imperfect expansion of the 
lungs and defective hsematosis. According to his view it is a slow 
asphyxia, the body becoming gradually cooled down and the child re- 
maining in a state of organic torpor until death occurs. 

Symptoms. — -The disease presents some variety of symptoms according 
as it occurs in early infancy or in more advanced life. 

In infants the induration of the skin appears within two weeks after 
birth, either with or without a preceding febrile condition for a day or 
two. It invades successively the feet, hands, limbs, the back, the face, 
and finall} 7 involves the entire surface of the bocly. At this early age, 
the skin retains its reddish tint in the affected part; whilst later in life, 
the surface assumes a dull, slightly j^ellowish aspect. The skin becomes 
hard, is with difficulty pinched up, and instead of thinning, remains thick 
and waxlike. The parts appear somewhat swollen, though never to any 
great extent, and pressure with the finger scarcely leaves an impression 
on their surface. Occasionally the induration is associated with an 
•effusion of serum beneath the skin, and when this exists, the surface is 
much more readily indented. 

i Diseases of Children (3d Amer. ed.), p. 238. 

2 Diseases of Infancy (Bird's trans.). 

3 Letourneau, Sclerema and (Edema. Paris, 1858 (Canstat. Jahrb., iv. 456). 



SYMPTOMS — PROGNOSIS. 867 

It is this occurrence of cedema which has led some observers to con- 
sider sclerema as a form of anasarca; it is probable, however, that its 
presence is merely a result of the obstructed cutaneous circulation, and 
that it does not, in realnVv, constitute an essential element of the disease. 
The skin is also quite frequently jaundiced. The children usually pre- 
serve the power of moving the affected parts, and there is no loss of 
cutaneous sensibility. The temperature of the body, and especially of 
the indurated portions, rapidly decreases, so that from 100° it may fall 
to 90°, 80°, and even, in some exceptional cases recorded by Roger, to 
Y3° and 70°. 

The little patients appear to suffer much pain during this disease. They 
utter a sharp, abrupt, isolated, but very frequently repeated cry, quite 
characteristic of the affection, and occasionally they present nervous 
symptoms, such as twitching of the hands or more general convulsive 
movements. 

The strength fails rapidly, and they soon become too weak to suck. 
The pulse is feeble, though not much accelerated, unless some complica- 
tion has ensued. The appetite fails, and the bowels are constipated, 
unless there is entero-colitis, which occurs in a few cases. This condition 
is naturally attended with great emaciation, as we find in Elsaesser's 1 
cases, where the average loss of weight was three-fourths of a pound, the 
extremes being six ounces and two pounds. \ 

The respirations are imperfect, and, after a short time, cough makes its 
appearance and continues throughout the case, indicating the occurrence 
of either pneumonia or collapse of the lungs, which are by far the most 
frequent complications, even if the state of atelectasis be not regarded as 
an efficient cause of sclerema. The disease, however, is not always so 
general and severe as above described; occasionally it occurs in limited 
portions of the body, and without any very alarming symptoms. 

In later life the disease is more frequently thus limited to small por- 
tions of the body ; the symptoms follow a more chronic course, and are 
somewhat amenable to treatment. Rilliet and Barthez 2 describe an acute 
and chronic form, and mention the following symptoms as distinguishing 
the disease in the adult : the severe epigastric pain associated with vio- 
lent palpitations, the less acute progress of the case, and the more fre- 
quent implication of the serous membranes. 

In one well-marked case, occurring at the age of thirty-five years, which 
one of us had the opportunity of observing during its entire course, these 
symptoms were very prominent. 

Prognosis. — In infants, when the induration is at all general, the dis- 
ease almost invariably terminates fatally in from two to six days. Under 
favorable circumstances, however, and when the induration is limited, 
resolution may occur, and the case terminate favorably; though it re- 
quires from fifteen days to a month to effect the cure. 

The fatal result is either caused by the gradual exhaustion of the vital 

1 Sclerema, Arch. Gen. N. S., t. i, 1853, p. 531. 

2 Op. cit., t. ii, p. 106. 



868 SCLEREMA. 

powers, or b} T the supervention of one of the complications already men- 
tioned, by far the most usual of which are lesions of the lungs. 

In later life, when the disease tends to recovery, a long time may be 
consumed before the induration completely disappears. Rilliet and Bar- 
thez report a case, occurring in a girl aged eleven years, which lasted two 
years, although it was at no time very general or accompanied by very 
severe symptoms. 

Of 53 cases reported by Elsaesser, all but 4 proved fatal, either from 
the sclerema itself, or from some incidental disease. 

Diagnosis. — The absence of airy lesion of the internal organs, together 
with the perfectly characteristic appearances of the induration, render an 
error of diagnosis almost impossible. 

Anatomical Appearances. — The induration of the surface persists 
after death, and on incising the part, a turbid fluid, resembling that of 
anasarca, often flows out. The subcutaneous tissue is also indurated, 
and the fat is found in the form of solid granules. This la}~er, which 
varies from one-half a line to three lines in thickness, is sometimes fol- 
lowed by a gelatinous one. 

The fluid which is contained in the meshes of the tissues has been sub- 
jected to analysis b}' several observers, but with conflicting results : 
Chevreul and Breschet reporting that it contained a plastic matter, spon- 
taneously coagulable on contact with the air, which they were inclined to 
regard as characteristic of the disease ; whilst Billard, on repeating this 
observation with fluid derived from an ordinary case of anasarca, found it 
to possess the same property. This subject, therefore, of much impor- 
tance in regard to the pathology of sclerema, requires to be more fully 
investigated. 

The indurated tissue is traversed try numerous vessels, permeable, and 
for the most part gorged with dark blood. Bouchut believes that the 
cutaneous capillaries are in great measure obliterated in the indurated 
parts, and that the oedema which occasionally coexists with sclerema is 
due to this obliteration; founding his opinion upon an unsuccessful at- 
tempt to inject the skin of a limb affected with sclerema, although the 
injecting fluid freely entered all the deeper tissues. The observations of 
Elsaesser, however, render this view doubtful, since in 49 cases, he failed 
to find this condition. 1 

Apart from these morbid changes in the skin and subcutaneous tissue, 
there is no lesion characteristic of sclerema. In a large number of cases, 
however, the lungs present some abnormal condition. According to 
Bouchut, they are often gorged with blood, and here and there contain 

i We have only space for a reference to the elaborate paper on keloid, scleriasis, 
and morpbcea, by Dr. Hilton Fagge {Guy's Hospital Reports, 3d S., vol. xiii, 1818, p. 
255), in which the clinical history of sclerema in the adult is fully detailed ; and to 
the valuable contributions to the pathology of this disease by Kasmussen (Trans, in 
Edin. Med. Jour., vol. xiii, part i, pp. 200 and 318). According to this latter ob- 
server, the essential element in the changes of the skin in sclerema, consists in a 
marked development of lymphoid cells, by multiplication of the cells in the perivas- 
cular sheaths of the minute bloodvessels of the derm and subcutaneous tissue. 



ANATOMICAL APPEARANCES — TREATMENT. 869 

patches of lobar pneumonia ; conditions which he regards rather as the 
result than the cause of sclerema. 

Elsaesser found lobular pneumonia present in a tenth of his cases; and 
in a third of them, portions of the lungs were impermeable to air. We 
have already stated that West, following the researches of Bailly and 
Legendre on atelectasis, believes that sclerema is one of the results of 
this persistence of the foetal condition of the lung, not differing in its 
essential nature from oedema following pulmonary obstruction. The oc- 
currence of undoubted cases of sclerema in the adult, and the frequent 
absence of atelectasis in well-marked cases of sclerema in infants, appear, 
however, to render this view untenable. 

The entire venous system and the cavities of the heart are distended 
with dark fluid blood ; but the heart presents no constant condition to 
which could be attributed the production of the disease. The jaundice 
which has been mentioned as occasionally existing, is not found to be 
associated with any abnormal condition of the liver, excepting conges- 
tion. Entero-colitis is a rather frequent complication of sclerema, and 
has been regarded as influencing its development ; but this view has long 
since been abandoned. Elsaesser found intestinal lesions and hyperaemia 
of the abdominal viscera quite commonly ; and, in eight of his cases, peri- 
tonitis was present. 

Treatment. — The preventive treatment of sclerema consists in atten- 
tion to all the lrygienic conditions of the young infant. 

The curative treatment implies the removal of all the causes, and the 
application of remedies calculated to restore the force of the circulation, 
and the function of the skin. Warmth stands foremost as a curative 
measure, and recourse may be had to warm baths or hot vapor baths, and 
to frictions with hot oil ; hot sand or bran-bags may be applied to the 
surface, and the temperature of the room should be carefully regulated. 

The child should be nourished with breast-milk; and stimulants, such as 
wine-whe3 T , should be freely given. Cordial and aromatic draughts are also 
recommended, which ma}- be formed of any of the diffusible stimulants. 

As there is reason to believe that some relation exists between sclerema 
and atelectasis pulmonum, we should, in addition, resort to all those 
means especially adapted to remove this condition, for a full account of 
which the reader ma} T refer to the article on collapse of the lungs. 

The same plan of treatment is advisable in cases in adult life. 

By these means we may hope to arrest, and even cure this strange 
affection, when it has not involved any considerable portion of the surface. 



CLASS VIII. 

WORMS IN THE ALIMENTARY CANAL. 



GENERAL REMARKS. 

There are five different species of worms found in the alimentary 
canal. These are the Ascaris lumbricoides, or round worm; Ascaris 
vermicularis, thread-worm, seat-worm, or. as it is popularly called, asca- 
rides ; Tricocephalus dispar, or long thread-worm ; Taenia solium, com- 
mon tape-worm, or long tape-worm ; and the Bothriocephalus latus, taenia 
lata, or broad tape-worm. 

We shall give a short description of each of the intestinal entozoa, in 
order that tluBy ma} r be readily distinguished, but will treat of the causes, 
symptoms, and treatment only of the first two, inasmuch as the tsenias 
very rarety exist during infancy or childhood, and the tricocephalus is 
much less frequent than the round and seat-worms, and gives rise to 
symptoms of the same kind as the former. 

Description. — The Ascaris lumbricoides, or, as it is commonly called, 
lumbricoides, lumbricus, or round-worm, is shaped not unlike the com- 
mon earth-worm, having a cylindrical body, which is attenuated towards 
either extremity, but particularly the anterior. It varies in length gen- 
erally between six and twelve inches, and is usually about two or three 
lines in thickness. The young worm, about an inch and a half long, is 
rarely met with. The head of the animal is at the smallest extremity, 
and maj 7 be distinguished bj r a circular depression, around which may be 
seen three tubercles. When recently voided the worms are somewhat 
transparent, so that the viscera may sometimes be seen through the pa- 
rietes. The integument is marked by circular fibres, and \>y four lines 
extending at equal distances from the head to the tail, the former of which 
indicate the course of the muscles, while the latter indicate that of the 
vessels and nerves. 

The color of the worm is whitish, 3 T ellowish, or more or less deep rosy 
in tint, according to the nature of the aliment thej T contain ; they are, as 
already stated, somewhat transparent when first voided. The alimentary 
canal, which may be distinguished by its brownish color, terminates by 
a transverse opening or anus, situated on the inferior surface of the 
animal, just in front of its posterior extremity. 

The two sexes are in different individuals. The male may be known 
by its tail, which is shortly curved, while that of the female is straighter 
and thicker. The genitals of the male consist of a double penis, which 



DESCRIPTION. 871 

may sometimes be seen to protrude just in front of the caudal extremity; 
those of the female may be distinguished b} T the vulva, seated at a con- 
stricted point of the body, about a third of the distance from the head to 
the tail. The male is smaller and much less abundant than the female. 

The Ascaris or Oxyuris vermicularis, thread-worm, seat-worm, or 
maw-worm, is the smallest of the intestinal worms, and is generally dis- 
tinguished in popular language by the title of ascarides. The sexes are 
in separate individuals. 

The male is generally about two lines in length; its body is elastic, of 
a whitish color, very slender, and looks not unlike a piece of cotton 
thread, whence one of its names was derived. The female is larger than 
the male, reaching a length of four or five lines. The anterior part of the 
bod}' is of the same shape in both sexes. It is obtuse, and surrounded 
by a transparent membrane, through which may be seen a straight tube, 
forming a kind of bladder, which is the oesophagus, and which terminates 
in a globular stomach. The head is provided with three tubercles, as in 
the lumbrieoides. The intestinal tube in the male continues the whole 
length of the body, which becomes somewhat thicker towards the end, 
and is arranged into a spiral shape at the tail. The body of the female 
is shaped like that of the male as far back as the stomach, and increases 
in size in the first third of its length, after which it diminishes, and be- 
comes so small at the end as to be seen with difficulty by the naked eye. 

The Tricocephalus dispar, or long thread-worm, is generally about an 
inch and a half or two inches long, and consists, as it were, of two por- 
tions, of which the anterior, constituting about two-thirds of the length, 
is exceedingly slender, scarcely thicker than a horse-hair, while the pos- 
terior third swells out suddenly so as to become much thicker and larger. 
The sexes are in different individuals. The worm is provided with an 
alimentary canal, which, commencing at an orbicular mouth placed in 
the small extremity, runs through the animal to the anus, placed at the 
caudal extremity. The male is smaller than the female, and is, usually, 
found convoluted. This worm is met with chiefly in the ccecum and colon, 
particularly the former. It usually exists in very small numbers, and 
sometimes but a single one is found. The symptoms which it occasions 
are the same as those produced by the lumbrieoides. 

The Tsenia solium, common or long tape-worm, as well as the Taenia 
lata, are of rare occurrence in children. Of 206 cases observed b}^ M. 
Wavruch, only 22 occurred in subjects under fifteen years of age, and of 
them the }'Oungest was three years and a half old {Bib. du Med. Prat., t. 
v, p. 626). These worms have, however, been met with at an earlier age, 
but as they are rare, we deem it unnecessary to do more than describe their 
appearance, in order that the reader may be able to distinguish between 
them and the varieties which generally exist in children, the Ascaris 
lumbrieoides and vermicularis. For a full account of the s3'mptoms pro- 
duced by the two varieties of the tsenia, and their treatment, the reader 
is referred to any of the standard works on the practice of medicine. 

The Tsenia solium is usually of a whitish color, flat in form, and vary- 
ing in length from five to ten feet, its ordinary length, to sixty, or even, 



872 worms. 

according to the assertion of some writers, upwards of a hundred. It is 
uneven in shape, being thick and rounded behind, and measuring three or 
four lines at its widest part, while it tapers gradually towards the anterior 
extremity, where it becomes slender and thread-like. The head is minute 
in size, and flattish in shape, with a projecting papilla in the centre, fur- 
nished with a double circle of hooks, and surrounded by four cylindrical 
apertures, which seem to be the mouths of the animal. The body is com- 
posed of numerous segments, which are longer than broad at the posterior 
part of the worm, and resemble, when separated, the seeds of a gourd, 
and have hence been called cucurbitani. In this worm the two sexes 
exist in the same individual. 

The Bothrioceph alus latus. Taenia lata, or broad tape-worm, is long and 
flat like the preceding variety, but it is generally thinner and broader, 
measuring from four to ten lines in breadth. It sometimes attains, like 
the common tape-worm, to a very great length. It is usually of a dirty- 
white color, and rather less opaque than the taenia solium. It is dis- 
tinguished also, says Dr. Wood, from the other taenia, bj T the shape of the 
segments, which are broader than the}' are long; by the form of the head, 
which is small, elongated, without spines, and divided into two lobes by 
a longitudinal fossa on each side ; and by having, instead of the four 
mouths of the taenia solium, a single minute pore in the centre, between 
the fossae, or else two pores, one at the extremity of each lobe. 

The frequency of intestinal worms, and their importance as a cause of 
disease, have certainly been, and are still Iry many physicians, and espe- 
cially by the public, very greatly exaggerated. There can be no doubt 
that they do, when they exist in large quantities, and particularly in 
certain countries, give rise to great disturbances of the digestive organs, 
and even occasion death ; but such instances are, it seems to us, ex- 
tremely rare in this cit} T at least. We are quite sure that we have never 
as } T et met with a case, in our own experience, in which life was at all 
seriously endangered by their existence, — though we have seen numerous 
instances in which slight disorders of the digestive apparatus, and vari- 
ous nervous s}"mptoms, generally of veiy moderate severity, have disap- 
peared after the administration of anthelmintics, sometimes followed, and 
in an equal number of cases probably, not followed, by the expulsion of 
worms. 

To show the truth of the above remarks, as to the importance of worms 
as a cause of disease, we make the following quotations : Dr. Rush (Med. 
Inquiries and Observations, vol. i, p. 205), remarks: " When we consider 
how universally worms are found in all young animals, and how fre- 
quently they exist in the human body, without producing disease of any 
kind, it is natural to conclude 'that they serve some useful and necessary 
purposes in the animal economy." M. Guersant says (Diet, de Med., t. 
xxx, 669): "It has always been the custom to assign to entozoa much too 
important an influence upon the diseases of childhood. In proportion as 
this part of pathology is perfected, it becomes evident that the greater 
number of children dying after having discharged worms, or even while 
having them still, are affected with acute or chronic diseases, which leave 



ASCARIS LUMBRICOIDES. 873 

after death incontestable traces of their effects, and which are of them- 
selves necessarily fatal." M. Barrier ( Mai. de V Enf., t. ii, p. 100) quotes 
M. Trousseau as making the following remarks : " For sixteen 3 T ears we 
have not met with a single child who has presented any verminous symp- 
toms ; never or almost never does a child born and reared in Paris dis- 
charge worms, while just the contrary is true as to the provinces 

Young children, to be sure, are sometimes met with in our hospitals, who 
discharge worms, but they are those who have been born in the coun- 
try, and have lived in the capital only for a short time." Dr. Con die 
(Dis. of Child., 2d ed., p. 226), remarks: u Worms are a very common 
occurrence in the intestines of children, and may unquestionably , under 
certain circumstances, become a cause of severe irritation ; but much less 
frequently than is generally supposed." 

We believe we may conclude, therefore, that though these parasites are 
of very common occurrence, and productive of grave disorders in some 
countries, they are rarely met with in quantities sufficient to do serious 
injury to the health, in other places, as for instance, Paris, and probably 
in this country, or at least in the northern parts of it. 

That intestinal worms do, however, not unfrequently in some countries, 
and occasionally in all, produce dangerous and even fatal disturbances 
of the health, cannot be doubted after careful perusal of the evidence 
brought forward by different authorities. M. Guersant, amongst others, 
remarks (Joe. czY., p. 670): "It is nevertheless incontestable, that the 
development of these animals in the gastro-intestinal and abdominal 
cavities, does sometimes give rise to very varied morbid phenomena, 
which are in some instances grave enough to cause death." Neverthe- 
less, we are disposed to believe, as stated above, that fatal, or even dan- 
gerous results from the existence of these parasites, are of rare occur- 
rence in this city, and probably throughout our Northern States. Dr. 
Dewees, however, mentions several cases in which they produced alarm- 
ing symptoms, and one in particular (Dis. of Child., p. 492), in which the 
subject, a child twenty months old, was extremely emaciated, and whose 
abdomen was "enormously distended, and semi-transparent," who re- 
covered rapidly after ninety-six lumbricoides, from six to ten inches long 
each, had been expelled under the use of pink-root in infusion. 



ARTICLE I. 

ASCARIS LUMBRICOIDES. 

The description of this worm has already been given at page 870. 

Causes. — Under this head we shall not pretend to consider the ques- 
tion of the origin of worms, but only the causes which predispose to their 
production, or favor their growth. 

Age has no doubt a considerable influence upon the predisposition to 



874 ASCARIS LUMBRICOIDES. 

lumbricoides. According to M. Guersant (loc. cit., p. 685), infants at the 
breast under six months of age are very rarely affected with them. In- 
stances occasionally occur, but are altogether exceptions to the general 
rule. Above six months of age, they begin to be met with, but still very 
rarely, so that scarcely one or two will be found in several hundred chil- 
dren of a very early age ; while from three to ten years of age they will 
be observed in about a twentieth, or in some seasons perhaps in a larger 
proportion. M. Yalleix states that he has never met with them in new- 
born children. Dr. Dewees says (loc. cit, p. 481), that he has never seen 
worms in children under ten months old; and in only two instances at 
that age. We do not recollect ourselves ever to have seen them in sub- 
jects younger than eighteen months, and very rarely in those under three 
or four years. 

There can be little doubt that the disposition to worms is hereditary in 
some families. It is generally believed that the species under considera- 
tion is more common in girls than boys; that it is most common in chil- 
dren of lymphatic and scrofulous constitutions ; and that a too exclusively 
vegetable or milk diet, and an abuse of fruits, strongly predispose to their 
production. The habitation of a cold and damp, or warm and damp 
climate, and the seasons of summer and autumn, are supposed by many 
also to favor their production and growth. It is a general belief, and we 
should suppose from personal experience, a well-founded one, that a feeble 
and disordered state of the digestive function from any cause, often acts 
as a predisposing cause of worms, and particularly of lumbricoides. 

Seats. — The small intestine is, in a very large majorhy of the cases, 
the seat of the ascaris lumbricoides. They are met with, however, in 
other parts of the digestive tube, particularly the stomach and large in- 
testine, and more rarely in the oesophagus or pharynx. In some instances 
they are found to have migrated to other organs, as to the liver, gall- 
bladder, and in still rarer cases, they have passed into the peritoneal 
cavity, bladder, larynx, trachea, bronchia, and even into the nasal pas- 
sages and frontal sinuses. They have also been met with occasionally in 
the walls of the abdomen, forming verminous abscesses, whence they 
have escaped on the opening of the abscess. 

The number of ascarides is exceedingly variable ; there ma} 7 be only 
two or three, ten or twenty, or several hundred. When very numerous, 
they are apt to be rolled or twisted into knots or balls, which have been 
seen as large as the fist, so as to block up completely the canal of the 
intestine. In a case cited by Rilliet and Barthez, from M. Daquin, the 
duodenum was so filled with worms as to be distended and to have 
acquired a considerably larger size than natural, while at the same time 
it was hard and elastic. The jejunum, ileum, and caecum were filled, so 
that it seemed as though the worms must have been pushed in bj" force. 
They were found also, but in smaller quantity, in the colon. Dr. Condie 
(loc. cit., p. 230) states that he has known one hundred and twenty lum- 
bricoides to be voided in a single day, by a child five years old. It ought, 
however, to be remarked, that the instances in which such large numbers 
are met with are altogether exceptional, especially in our Northern States. 



ANATOMICAL LESIONS. 875 

We have never ourselves known more than six, eight, or ten to be ex- 
pelled, within a few days' time, and very generally there have not been 
more than three, four, or five. 

Anatomical Lesions. — When the number of lumbricoides is small, the 
mucous membrane has been found in a state of perfect health, while, on 
the contrary, when they are numerous, and especially when collected to- 
gether into knots, the membrane has presented a fine injection like that 
which exists in eiythematous enteritis ; in some very rare instances on 
record, in which the quantity of worms has been very great, the mucous 
membrane has been found deeply injected, thickened, granulated, and, in 
a smaller proportion of cases, softened, and even eroded. Not unfre- 
quently the intestine presents all the characters of well-marked enteritis, 
or entero-colitis, though the number of worms may be very small. In 
such cases it is reasonable to suppose that the inflammatory affection has 
been an accidental complication of the verminous disorder. 

Much discussion has arisen in regard to the manner in which perfora- 
tion of the intestine, as an accompaniment of worms, takes place. It is 
necessary to suppose, in subjects in whom worms are found in the peri- 
toneal cavity, or in abscesses formed in the abdominal parietes, that per- 
foration of the bowel has taken place, and yet in some instances no trace 
of the opening is left, no inflammation of the serous membrane is met 
with, nor has there been any escape of the contents of the digestive canal 
into the abdominal cavity. In others, however, and much the most 
numerous cases, it is evident from the anatomical appearances, that the 
perforation has taken place in consequence of previous ulceration of the 
coats of the bowel, and that the worms have escaped with the other con- 
tents of the intestine. It is in regard to the former class, therefore, that 
discussion has principally taken place ; some asserting that the parasite 
itself makes the opening, b}- an active process, while others deny the 
possibility of this occurrence, and maintain a previous ulceration or soft- 
ening in all cases. Amongst those who advocate the possibility of per- 
foration independent of previous change in the intestinal coats by disease, 
are MM. Mondiere and Charcelay, the former of whom has examined the 
subject with a great deal of care, quoted by Rilliet and Barthez ; Rilliet 
and Barthez themselves ; the authors of the Biblioth. du Med. Prat*, and 
M. Guersant ; while amongst those opposed to this opinion may be cited, 
MM. Cruveilhier, Barrier, Dr. Arthur Farre, who greatly doubts the pos- 
sibility of the accident, and Dr. Condie. We confess ourselves inclined 
to believe, from facts stated by different authors, and from the history of 
two cases which occurred to M. Guersant in 1841, at the Children's Hos- 
pital of Paris (loc. cit., p. 680), that worms may in some instances cause 
a perforation independently of previous disease of the coats of the intes- 
tine. In one of these, two lumbrici were found engaged in an opening 
in the appendix vermiformis, half the bodies of the animals being in the 
appendix, and half in the peritoneal sac ; while in the other, an opening 
of the same kind as in the previous case was found in the appendix, and 
though the three worms which were found tying in the abdominal cavity, 
might have escaped through an ulcerated perforation of the colon, it is 



876 ASCARIS LUMBRICOIDES. 

not the less true that the opening in the appendix presented the same 
characters exactly as in the first case, in which the animals were, as the 
author remarks, "taken in the act." In both instances, the perforation 
of the appendix was at the extremity of that canal, and in the form of a 
narrow opening of a conical shape; the membranes were smooth, thinned, 
and the edges of the orifice sloped off from within outwards; no trace of 
anterior ulceration was perceptible. 

In regard to .the verminous abscesses alread} 7 referred to, we shall make 
but few remarks, referring the reader to more extensive treatises for fuller 
information. These abscesses have been, in very rare instances, met with 
in the pharynx and nasal passages, but much more frequently they exist 
in the abdomen. The latter may be of two kinds, stercoraceous and non- 
stercoraceous. In the former, the abscess, which forms upon some por- 
tion of the walls of the abdomen, gives issue not only to the worm or 
worms, and pus, but also to fecal and even alimentary substances, and 
leaves behind a fistula connecting with the cavity of the intestine, which 
may cicatrize after a short time, or remain open during life. In the other 
form of abscess, the opening through the coats of the intestine has been 
closed immediately after the passage of the worm, so that the abscess 
gives issue only to the animal and pus, after which it heals up without 
giving rise to a fistula. 

The verminous abscesses are said to be found generally about the in- 
guinal and umbilical regions ; to occur most frequently between the ages 
of seven and fourteen years, and not to be, as a general rule, very dan- 
gerous to life. 

Symptoms Indicative of the Presence of Worms. — TTe believe it 
is almost universally acknowledged hy later writers, that there is no sin- 
gle symptom, nor group of symptoms, other than the expulsion of the 
worms, and their detection, which indicate with certain ty their existence 
in the digestive tube. This is the expressed opinion, amongst others, 
of MM. Guersant, Rilliet and Barthez, Barrier, Yalleix, and Drs. Eberle 
and Condie, and it is also the opinion which we have ourselves been led 
to form from our experience amongst children. 

Another point wortlrv of remark is, that even though one or several 
worms may have been expelled, it is not always fair to conclude that the 
S3^mptoms under which the child labors, are the result of the presence of 
others of these animals, as there ma} 7 be no more in the bowels, or they 
may be so few in number as not to produce injurious effects ; while, on 
the contrary, various disorders of the digestive tube, as chronic indiges- 
tion, simple diarrhoea, and inflammatory diseases of the gastro-intestinal 
mucous membrane, ma} x and do exist simultaneously with, and yet inde- 
pendently of, the presence of these parasites. 

The symptoms generally enumerated as indicative of the presence of 
worms are the following. The child presents various signs of disturbed 
health. The stomach is more or less deranged, as shown by furred tongue, 
eructations, variable appetite, which is sometimes diminished, and some- 
times increased, thirst, acid or heav} T breath, and nausea. The abdomen 
maj' be enlarged or retracted, generally the former, and is often more or 



SYMPTOMS. 877 

less bard and painful to the touch; the condition of the bowels varies in 
different cases, as they are sometimes costive, and sometimes affected with 
diarrlnea. According to M. Guersant, the stools often contain glairy sub- 
stances, and are sometimes streaked with blood and of a 3-ellowish-green 
color; the patient often suffers from colics, which may be either dull or 
acute, though more generally the latter, and which are generally felt at 
the umbilical region. Children affected with lumbricoides are said to 
present a peculiar physiognomy ; the face is usually paler than natural, 
and sometimes has a leaden tint ; the eyes are surrounded by bluish rings, 
and have at the same time a dull and languid expression ; the inferior 
eyelids are often swelled and puffy ; the sclerotic coat of the eye assumes 
a bilious tint ; the nostrils are said to be sometimes swelled, and the child 
complains much of irritation and itching of those parts, and is constantly 
picking at them with the fingers. In some instances epistaxis takes place. 
The child is generally pale and thin, indolent and languid, or irritable 
and unhappy. The sleep is almost always disturbed. This indeed is, 
it seems to us, one of the most important signs both of worms and of 
chronic functional disorders of the stomach and bowels. The nights are 
almost always restless, the patient either waking often to drink, or waking 
in fright and alarm from dreams, or else constantly tossing and turning 
in sleep, moaning, or grinding the teeth. 

Other symptoms mentioned by different observers, and by some very 
much depended upon, are acceleration with irregularity of the pulse, and 
dilation, especially unequal dilation, of the pupils. We might cite also 
strabismus, and oceasionall\ T cough. 

In children in whom the number of lumbricoides is very large, the con- 
stitution suffers to a dangerous degree. The symptoms above enumerated 
are very marked, and at the same time the child is very pale or sallow, 
emaciated, weak, and without appetite; the abdomen is hard and tumid; 
the nervous symptoms are severe, and some of the symptoms which we 
shall describe presently, under the head of disorders occasioned by 
worms, are also observed. 

It should be remarked, however, again, that all or any of the sj^mptoms 
just described may exist independently of the presence of worms, the only 
certain sign of which is their expulsion from the patient. 

Morbid Effects Occasioned by Worms. — MM. Rilliet and Barthez 
divide the accidents or effects produced by the existence of lumbricoides 
into two groups: those which result from the mechanical influence of the 
entozoa, as their accumulation or displacement; and those which appear 
to be the consequences of a purely sympathetic action on the different 
S}^stems of the body, and particularly the nervous system. 

Mechanical Effects. — Under this head are included perforation and 
hemorrhage of the intestine, enteritis, abscesses, and the symptoms deter- 
mined by the displacement or migration of the worms into the ductus 
communis choledochus, liver, or air-passages. 

Of perforation and abscesses we have alread}^ treated under the head 
of anatomical lesions. Hemorrhage is a very rare event, but it occurred 
in one instance cited by MM. Rilliet and Barthez, and Guersant, from 



878 ASCARIS LUMBRICOIDES. 

M. Charcelay, in consequence of the rupture of an arteriole in a small 
rounded ulceration in the duodenum, apparently occasioned by the pres- 
ence of a large number of lumbrici. Enteritis, as an effect of the presence 
of worms, has also been referred to under the head of the anatomical le- 
sions. In many instances it is, no doubt, a mere accidental complication, 
in no wa} T connected with the presence of entozoa ; probably this is true of 
a large majority of the cases. When, however, the number of the para- 
sites is very great, and particularly when the} r are collected into large or 
firm knots and bundles, the} T ma} 7 , no doubt, occasion, by their mechanical 
irritation, inflammation, thickening, softening, and even destruction of 
the mucous tissue, as in cases cited by M. Guersant, from MM. Breton- 
neau and Charcelay, and in one which occurred to himself. It should be 
remarked, however, that the cases on record in which ulcerations evi- 
dently depended upon the presence of worms, are, so to speak, infinitely 
few in comparison with those in which no such alteration existed, or in 
which it was evidently independent of any influence exerted by the worms. 

Effects Caused by the Displacement or Migration of Worms. — 
Lumbricoides have been found, as we have already seen, in the walls of 
the abdomen, giving rise to abscesses. They have been discovered also 
in the ductus communis choledochus, in the gall-bladder, hepatic ducts, 
in the substance of the liver, forming abscesses, and in the pancreatic 
canal. The sjonptoins occasioned b} T the latter class of cases are very 
obscure. In one instance, M. Guersant supposed that an attack of con- 
vulsions depended upon the presence of worms in the common duct. 

More numerous examples are on record, in which violent dj'spncea and 
cough, and fatal asphyxia, have occurred in consequence of the pressure 
of lumbricoides which had passed into the oesophagus, or from their in- 
troduction into the larynx, trachea, or bronchia. The symptoms occa- 
sioned by these accidents are a sudden attack of dyspnoea, anxiety, agi- 
tation, threatened suffocation, dry, spasmodic cough, acute, painful cries, 
pain in the larynx or trachea, and, unless relief be obtained in a few hours, 
death. This kind of attack may depend on the rising of a worm or bundle 
of worms into the oesophagus, causing pressure on the larynx and trachea, 
as in the case reported by M. Tonnelle, in which the sj^mptoms disap- 
peared after the expulsion of a large number of worms. One of us has 
met with an instance of this kind. It occurred in a boy fifteen years old, 
presenting every mark of strong and vigorous health, but who, for three 
or four weeks before we were consulted in regard to him, had been sub- 
ject to sudden and apparently causeless attacks of suffocation, which 
seized him without the least warning. When the attack came on, he 
would for some instants cease to breathe, or breathe with much difficulty. 
He alwa} T s seemed to suffer from the greatest anxiet} 7 ; the countenance 
became altered and distressed ; he was unable to speak, but made signs 
for water, and when able to swallow a mouthful, which was alwa} T s ex- 
ceedingly difficult, was at once relieved. His mother told us that he 
always appeared to be in the greatest distress, so that, on several occa- 
sions, she feared for his life. Striking him violently on the back, which 
she, when present, always did, sometimes relieved him, but generally the 



SYMPTOMS — DIAGNOSIS. 879 

difficulty continued until he could swallow a little fluid of some kind. 
These attacks were unattended at the time b}^ cough, nor was there the 
least sign of disorder of the respiratory system in the intervals between 
them. Suspecting that the difficulty must depend on the rising of a 
worm or worms into the oesophagus, or upon sympathetic irritation from 
the presence of these parasites in the stomach, and learning that he had 
been troubled with worms some years previously, we gave him wormseed 
oil, which caused the expulsion of a few large lumbricoides, after which 
he had no return of the s} T mptoms. 

The attacks of d} r spncea may depend also, as already stated, on the 
introduction of worms into the air-passages. Under these circumstances 
death is very apt to be the result. In one instance, however, reported 
by M. Arronsshon, after the difficulty had lasted two hours, the patient, 
a little girl eight years old, after violent efforts at coughing, threw up a 
living lumbricus. 

We have next to consider the sympathetic effects, and particularly the 
nervous symptoms, occasioned by worms. We may include amongst the 
nervous symptoms produced by worms the headache, languor, irritability, 
restless and disturbed sleep, and grinding of the teeth, so frequently ob- 
served. These, however, are of but slight importance in comparison with 
certain other disorders of the nervous system, which do undoubtedly 
occur sometimes, though we should suppose very rarely, in proportion 
to the whole number of subjects affected with the parasites. The disor- 
ders to which we allude are partial or general convulsions, chorea, hyste- 
ria, catalepsy, and epilepsy, which are the most frequent, though, as so 
often stated already, extremely rare in comparison with the number of 
cases in which the presence of the worms produces no such effects. 
Other disorders cited by the authors of the Bib. du Med. Prat., with cases 
to prove their reality, are insanity, paralysis, coma, palpitations, strabis- 
mus, cough, hyperaesthesia of the skin, amaurosis, and aphonia. 

Diagnosis. — It has already been stated that there are no certain signs 
of the presence of worms in an individual except their expulsion. The 
sj^mptcms which have seemed to us most strongly to indicate their 
presence are, a chronic disordered state of the digestive apparatus, pro- 
ducing irregular appetite, which is sometimes good and at others bad ; 
slight emaciation ; paleness or unhealthy tint of the complexion; languid 
expression of the face ; some irritability of the temper, or a want of the 
gayety and activity of disposition natural to childhood ; picking at the 
nose ; often some tumidity of the abdomen, which may be at the same 
time either hard or merely t3 7 mpanitic ; and, what seems to us more im- 
portant than any that we have named, very restless and broken sleep at 
night, with frequent grinding of the teeth. 

M. Valleix remarks that, in a case presenting nervous symptoms simu- 
lating disease of the brain, we may suspect the existence of worms, if we 
learn upon inquiry that symptoms of marked intestinal disorder, the 
various signs cited above as indicative of the presence of worms, and 
different derangements of digestion, had preceded for some time the 



880 ASCARIS LUMBRICOIDES. 

appearance of the nervous symptoms; chiefly for the reason that, in most 
diseases of the brain, the digestive tube is, at the invasion, in a state of 
integrity, with the exception of sj'mpathetic vomiting. If we can learn, 
upon inquiry, that the child has discharged worms on some previous 
occasion, the probabilitj- of the dependence of the symptoms upon them 
becomes still stronger. 

It is sometimes difficult to determine positively whether certain sub- 
stances discharged at stool are fragments of worms, or whether they are 
portions of imperfectly digested aliment, or foreign bodies. The things 
which most resemble lumbricoides, are the remains of tendons, ligaments, 
vessels, fibres of plants, &c. To make the distinction with certainty, 
the doubtful substance ought to be placed in water, so that it may be 
thoroughly cleansed, after which it must be carefully examined as to its 
structure, arrangement, consistence, &c, with the e} T e, and with the 
microscope, if necessaiy. M. Guersant has suggested a very easy method 
of ascertaining whether the substance be animal or vegetable, which is 
to subject it to heat, after it has been carefully washed, when the odor 
will at once inform us of its real nature. 

Prognosis. — It is no doubt a very rare event, at least in the northern 
parts of our country, for life to be endangered by the presence of worms. 
We have never, ourselves, met with an instance in which the general 
health was more than moderately disturbed by this cause. That vermin- 
ous affections are sometimes, however, dangerous to life in this city, is 
shown by three cases related by Dr. Dewees, in which very severe and 
threatening symptoms were instantly relieved upon the expulsion of lum- 
brici after the exhibition of vermifuges. 

Worms become dangerous to life when they migrate from their original 
seat to neighboring and important organs, particularly the air-passages 
and liver. The prognosis is unfavorable also when the} r accumulate in 
veiy large numbers, and give rise to the different nervous symptoms 
above described. 

Treatment. — Before commencing our remarks upon the particular rem- 
edies employed for the destruction and expulsion of worms from the ali- 
mentaiy canal, we would call the attention of the reader to the fact that 
most of the recognized anthelmintics are more or less irritating to the 
gastro-intestinal mucous membrane, and some of them to the nervous 
system also, producing, in overdoses, severe and even dangerous nervous 
symptoms. It is evident, therefore, that remedies of this class ought not 
to be exhibited unless they are manifestly called for, and not at all when 
sjmaptoms of severe gastro-intestinal irritation, and particularly of inflam- 
mation, are present, unless there be the very strongest reasons for sup- 
posing that those symptoms depend upon accumulations of worms. We 
are quite sure that we have, in a considerable number of instances, met 
with children whose digestive organs had been injured, and in whom 
slight functional derangement had been converted into severe indigestion, 
and even inflammatory disorder, by the too frequent or long-continued 
use, or the administration in excessive quantities, of different vermifuges, 



TREATMENT. 881 

and of various quack nostrums, which are sold to an amazing extent in 
this city, and all over the country. 

As the diagnosis of worms is always doubtful, it is best never to risk 
the administration of any of the irritating vermifuges, unless convinced, 
by the previous expulsion of worms, that they are almost certainly pres- 
ent ; and, indeed, we ourselves rarely give any other remedy than small 
quantities of the wormseed oil in slight, and especially in doubtful cases, 
unless this has already been tried and failed. From our own experience, 
we believe that this remedy is all-sufficient in a large majority of the 
cases that occur in this city, as these are almost always of a mild char- 
acter, and as it not only produces the expulsion of the parasites when 
they exist, but also acts beneficially upon the forms of digestive irritation 
which simulate so closely the sjmiptoms produced by worms. We are 
persuaded, indeed, that of all the cases that have come under our notice, 
in which it seemed probable that worms might be present, none were 
expelled in nearly half, and } T et the signs of disturbed health have passed 
away under the use of the remedy. The oil of wormseed may be given 
in doses of four drops to children of two years of age, and of six or ten 
to those above that age, three times a day for three days, to be followed 
on the morning of the fourth day by a moderately active, but not irritat- 
ing cathartic dose, the best of which is castor-oil or syrup of rhubarb. 
The objection to the remedy is its nauseous taste and smell; these, how- 
ever, may be partially disguised by making it into a mixture with yolk 
of egg^ powdered gum, and sj< rup of ginger. Some children take it very 
well dropped upon a lump of white sugar, while others take it best mixed 
with common brown sugar. If one course of the oil, as it is called, fail 
to relieve the sj^mptoms, another should be administered. It ought to 
be recollected that, when given in large doses, the wormseed oil is irritat- 
ing to the digestive mucous membrane, and produces dangerous nervous 
symptoms. We know of one case, in which a girl six or seven years of 
age was made exceedingly ill, and suffered for years afterwards, from the 
effects of a teaspoonful of the oil given by mistake. The following is a 
very good formula for the administration of this remedy : 

R. — 01. Chenopodii, .... gtt. lx vel fgj. 
P. G. Acacise, .... ^ij. 
Syrup. Simp., . . . . f^j. 
Aq. Cinnamom., .... fgij. — M. 
Give a dessert-spoonful three times a day, for three days, and repeat after several 
days. 

The wormseed may be given also in powder, in the dose of from twenty 
to forty grains. 

The remedies most frequently employed in this country besides the 
wormseed, are pink-root or spigelia, oil of turpentine, calomel, and the 
bristles of cowhage. 

We believe that the pink-root is more depended upon amongst us than 
any other single remedy. It is given either in substance or infusion. 
The dose of the powder is from ten to twenty grains for a child three or 

66 



882 ASCARIS LUMBRICOIDES. 

four years old, to be repeated every morning and evening for several 
days, and followed by an active cathartic. The powder is seldom used, 
however, as the drug is almost always given in infusion. The best and 
safest mode of administering it is in combination with cathartic sub- 
stances. Thus, half an ounce each of pink-root and senna may be in- 
fused for a few hours in a pint of boiling water, and a tablespoonful 
given two or three times a day to children two or three years old, for 
three, four, or five days, when it should be suspended for a time, and 
resumed, if necessaiy. A preparation much used in this city under the 
title of worm-tea, and which %re have ourselves given with verj T good suc- 
cess, consists of the spigelia mixed with senna, manna, and savine, in 
different proportions, made into an infusion and sweetened with brown 
sugar. Dr. Gr. B. Wood (Pract. of Med., vol. i, p. 626), recommends the 
following formula : 



-Sennas, Spigelian, . 


aa gss 


Magnesiae Sulphat., 


• 3iJ- 


Manna?, .... 


. • • a- 


Foeniculi, 


• 5J- 


Aquae Fervent., 


• • • Oj. 



These are to be macerated for two hours in a covered vessel, and a 
tablespoonful given to a child two years old once or twice a day, or every 
other day, so as to procure two or three evacuations in the twentj^-four 
hours. The remed} r is continued for a few days, or for one or two weeks, 
if necessary, and if it do not debilitate the child. 

The spirit of turpentine is highly recommended as an efficient remedy 
for worms by several authorities, and particularly by Dr. Joseph Klapp 
and Dr. Conclie, of this city. Dr. Condie states that it is the article from 
which he has derived the most decidedly beneficial effects, and remarks 
that it may be given when there exists considerable irritation of the ali- 
mentary canal, or even subacute inflammation, without anj T fear of its 
increasing either. . He gives the rectified spirit in sweetened milk, in 
molasses, or in the following mixture : 



R. — Mucil. G-. Acacise, 


. . . . fgij. 


Sacch. Alb., 


. 3x. 


Spir. ^Ether. Uitr., . 


■ • • • f&iij. 


Ol. Terebinth., . 


. . . f^iij. 


Magnes. Calcinat., . 


• • • • Bj. 


Aquae Menthae, . 


. . . f^j.-M. 



Of this mixture a dessert-spoonful is given every three hours. 

We have used the spirit of turpentine but seldom, on account of its ex- 
tremely disagreeable taste, having always succeeded perfectly well with 
the wormseed oil, or with infusion of pink-root with cathartics. 

Calomel also is highly thought of by many persons as a vermifuge, and, 
no doubt, when used in combination with or followed by cathartics, or 
given in full purgative doses, it is very effectual. We can only repeat 



TREATMENT. 883 

what we have already said on several occasions, that it is a remedy which, 
from the powerful influence it exerts upon the constitution, ought not to 
be given except when really called for ; and, as we can almost always suc- 
ceed in curing verminous affections by milder drugs, we see no occasion 
for resorting to this, except in rare cases. When used it is given alone 
in considerable doses, and followed b} 1- some cathartic, or in combination 
with rhubarb and jalap, or jalap, or scammony. 

The bristles or down of coichage are also used by some practitioners, 
no doubt sometimes with success. We have never used them, and can 
give no opinion, therefore, from personal experience, as to their efficacy. 
They are administered b}~ making them into an electuary with honey, 
syrup, or molasses, a teaspoonful of which is given every morning for 
three days, and then followed b} T an active cathartic. 

The following electuary, recommended by Bremser, is very much em- 
ployed in Europe, and is highly spoken of by Dr. Eberle : 

R. — Semin Santonicne (semen-contra of the French writers), 

Semin. Tanaceti rude contus., .... aa^ss. 

Valerian, pulv., gij. 

Jalapae pulv., ......... gjss-ij. 

Potass. Sulphat., ........ ^jss-ij. 

Oxymel. Scillae, q. s. — ut ft. 

Electuariuui. 

A teaspoonful of this is given morning and evening for three or four clays, 
when the dejections generally become more copious and liquid. If it do 
not produce this effect, Bremser advises that the dose be increased. Dr. 
Eberle gave it for six or seven days, and says it does far less good when 
it produces frequent and watery evacuations, than when it causes only 
three or four consistent stools a clay. This preparation has a very disa- 
greeable taste, and children sometimes refuse to take it on that account. 
When this is the case it may be made into pills. 

MM. Rilliet and Barthez recommend the following syrup, which was 
proposed and highly thought of by M. Cruveilhier : 

R. — Follicul. Sennse, Khei, Semin. Santonic, Artem. Abrotan., 

Helminthocort., Tanaceti, Artemis. Pontic, . . . aa gj. 
To be infused in half a pint of cold water, strained, and made into a syrup with sugar, 
of which a tablespoonful is to be given every morning for three days. 

M. Cruveilhier states that this syrup has been very successful in his hands. 
Of late years, santonine, the active principle derived from the European 
wormseed, has been much employed and with very good success. The 
remedy may be given in doses of from gr. ij to gr. v, combined or fol- 
lowed by a dose of castor-oil or senna. The empyreumatic oil of Chabert 
is also highly spoken of by some European authorities. It is made by 
mixing one part of the empyreumatic oil or fetid spirit of hartshorn, with 
three parts of spirit of turpentine, and allowing them to digest for four 
days. The mixture is then put into a glass retort, and distilled in a sand- 
bath until three-fourths of the whole have passed over into the receiver. 



884 ASCARIS LUMBRICOIDES. 

The product should be kept in small and tightly-closed vials. The dose 
is about fifteen or twenty drops three or four times a day, for children 
between two and seven years old. This is recommended highly by 
Bremser and other authorities. The great objection to it is its exceed- 
ingly nauseous taste. Dr. Eberle speaks in very favorable terms of a 
strong decoction of helminthocorton or Corsican moss, which he has found 
" not only valuable as a vermifuge, but particularly so as a corrective of 
that deranged and debilitated condition of the alimentary canal favoring 
the production of worms." An ounce of helminthocorton, with a drachm 
of valerian, are to be boiled in a pint of water down to a gill, and a tea- 
spoonful of the decoction given morning, noon, and evening. It is par- 
ticularly beneficial in cases attended with the usual symptoms of worms, 
connected with want of appetite and mucous diarrhoea, and arising from 
debility of the digestive organs, and a vitiated condition of the intestinal 
secretions. 

Kameela, the reddish-brown powder which clothes the capsules of the 
rottlera tinctoria, has been of late highly recommended, not only in cases 
of taenia, but of ascaris lumbricoides. 

The dose for children is about gr. v, repeated till it has acted on the 
bowels. 

In all cases of deranged health supposed, either from the nature of the 
symptoms, or proved by the previous expulsion of worms, to depend on 
the presence of these animals in the alimentary canal, it is exceedingly 
important to attend to the hygienic treatment of the child, and in some 
instances to administer tonics and stimulants. In not a few cases that 
have come under our own notice, in which many of the symptoms sup- 
posed to indicate the presence of worms have been extremely well-marked, 
we have succeeded in removing them all without a resort to any vermifuge, 
by the treatment proper for the chronic indigestion or dyspepsia of chil- 
dren. The method of treatment to be employed in such cases has already 
been laid down in the article on indigestion, to which the reader is re- 
ferred for full information. It should consist chiefly in strict attention 
to exercise and diet, and in the use of tonics, as quinia and iron, and 
small quantities of fine port wine. 

Whenever any complication exists in connection with worms, the treat- 
ment must be modified according to its nature. If it consist in inflam- 
mation of any part of the digestive tube, the inflammation ought to be 
attended to first, and the verminous disorder for the time neglected. 
If the inflammation be very slight, or, if the symptoms indicate only 
severe irritation rather than positive inflammatory action, we may ex- 
hibit the milder and least injurious vermifuges, as very small doses 
of wormseed oil, which we have never known to do harm, the decoc- 
tion of helminthocorton and valerian, recommended by Dr. Eberle, or, 
according to Dr. Conclie, the spirit of turpentine. If the verminous 
affection coexist with any of the acute local inflammations of the thorax, 
the former ought to be, as a general rule, neglected, until the latter has 
been relieved by appropriate treatment. In doubtful cases, in which it 
is impossible to ascertain with certainty whether the symptoms depend 



ASCARIS VERMICULARIS. 885 

on worms, or upon a simple chrspeptic condition of the digestive organs, 
it is most prudent to give only the simplest and least irritating vermi- 
fuges, to regulate the hygienic conditions of the patient, and afterwards 
to resort to tonics, if necessaiy. 

Various writers, and particularly M. Guersant, advise that we should 
forbid, in verminous cases, the use of relaxing food, especially of milk 
preparations, fruits, and of fatty and farinaceous substances; and that, 
after the expulsion of the worms, we should direct a tonic and strength- 
ening regimen. The diet should consist of boiled and roasted meats, of 
wine, and of bitters. The author just quoted, states that a change of 
food alone will often suffice to procure the expulsion of worms. He says 
(Diet, de Med., t. xxx, p. 689), "I have met with children who had been 
tormented with ascarides lumbricoides while residing in the country and 
living upon milk and fruits, and who, upon being brought to the city, 
and put upon the use of broths and soups, passed considerable quantities 
of worms, and after that got entirely rid of them." 



ARTICLE II. 

ASCARIS VERMICULARIS. 

The description of this worm has already been given at page 871. 

Seat. — The ascaris vermicularis is found almost exclusively in the 
large intestine, and in a large majority of the cases is confined to the 
rectum. It is said to have been found in the vagina in the female, having 
no doubt passed from the rectum into that canal. 

The causes which determine the presence of this worm are not at all 
understood. 

Symptoms. — The characteristic, and often the only symptom indicative 
of their presence, is violent itching about the anus, which is sometimes 
almost insupportable, and which is generally most troublesome and most 
apt to occur at night when the child is in bed. In some instances they 
give rise to acute and violent pain in the region of the anus, and some- 
times to tenesmus and mucous or bloody stools. When the last-named 
severe symptoms exist, the worms may occasion dangerous nervous dis- 
orders, and even give rise to general convulsions. The worms not unfre- 
quently escape from the rectum and are found upon the bedclothes, or 
upon the clothes which the child has worn through the day. Sometimes 
they are discharged in considerable numbers, and are found in that case, 
either 'mixed with the faeces, or with mucus, or collected into balls or 
knots. 

The diagnosis of the seat-worm, like that of the lumbricoides, cannot 
be regarded as positive, unless some have been expelled, or unless they 
can be seen by examination of the rectum. This can generally be done 
when they are present in any number, by pressing the nates apart so as 



886 ASCARIS VERMICULARIS. 

to open the anus and bring the folds of the mucous coat of the bowel into 
view. The only other sj'mptom which indicates their presence with any 
certainty, is the existence of severe itching about the anus, not to be ex- 
plained upon any more reasonable supposition. 

Prognosis. — These worms do not, as a general rule, produce the same 
disturbances of the general health as lumbricoides, aud in not a few in- 
stances are entirely innocuous, with the exception of the pain and incon- 
venience they occasion. 

They are, however, exceedingly troublesome, because of the difficulty 
of removing them entirety by any treatment. No matter how many are 
discharged, some almost always remain concealed in the folds of the 
mucous membrane, and, as they are propagated with great rapidity, the 
same train of symptoms is very apt to return soon after they may have 
been seemingly dislodged. 

Treatment. — It has been found by long experience that the common 
vermifuges given by the mouth, exert much less influence in causing the 
expulsion of these worms than of the lumbricoides. For this reason ene- 
mata are generally resorted to in the treatment, instead of remedies given 
by the mouth. Dr. Dewees, however, recommends the elixir proprietatis 
(tinct. aloes et myrrhae), in small and often-repeated doses, continued for 
some time, and followed by enemata of lime-water, camphor, or aloes. 
He gave twenty drops of the elixir three times a da} r , in a little sweetened 
milk, to children from two to four 3 T ears old, and thirty drops to those 
between five and seven years. 

The plan we have generally resorted to has been to give small closes of 
the wormseed oil, as directed in the article on lumbricoides, and to direct 
an injection of from four to six grains of powdered aloes, suspended in a 
gill of warm milk, for children four years old, to be repeated once in three, 
four, or five days, according to the necessity of the case. 

Lime-water by injection is recommended by several different authori- 
ties. It may be given of its ordinary strength, or mixed with an equal 
quantity of warm milk, or flaxseed mucilage. Other enemata recom- 
mended are spirit of turpentine in milk, a teaspoonful of the former to a 
gill of the latter; decoction of helminthocorton; an injection made bj- in- 
fusing two drachms of fresh garlic-cloves in three ounces and a half of 
boiling water, and adding to the infusion, after it has been poured off, a 
scruple of assafceticla rubbed up with the yolk of an egg ; a solution of 
from six to twelve grains of sulphuret of potassium in half a pint of water ; 
injections of sweet oil, or of lard beaten up with water until it becomes 
fluid, and even of cold water. The three last-mentioned substances have 
the advantage of calming the itching and irritation of the rectum almost 
immediately. Enemata of a solution of nitrate of silver, in the proportion 
of two to four grains to the ounce of water, have been recommended by 
Schultz (Deutsche Klinik, quoted in Med. Times and Gaz., 1858), who as- 
serts that two or at most three of these injections suffice to effect a cure. 
Again, it has been recommended to pass a bougie smeared with mercurial 
ointment into the rectum. We should much prefer a method of using this 
ointment which succeeded in the hands of M. Cruveilhier in a very severe 



TREATMENT. 887 

case. This was to place a little of tlie ointment on the anus, by which 
course the patient was entirely relieved after a few days. M. Valleix 
states that he has obtained the same results by causing the anus to be 
anointed with the following preparation, a small quantity of which was 
introduced at the same time into the inferior extremity of the intestine : 

R. — Hydrarg. Chlor. Mitis, .... ^iv. 

Axung., gvi. — M. 

Dr. Wood states that a dose of sulphur taken every morning before 
breakfast has been found very useful. 

The diet and general health ought always to be strictly inquired after, 
and attended to by the physician. For information upon these points 
the reader is referred to the remarks upon hygienic treatment in the last 
article. 



INDEX. 



Abdomen, examination of, and signs from, 
46, 47 
condition of in entero-colitis, 357,360 
in cholera infantum, 388 
in tuberculous peritonitis, 653 
in tuberculosis of mesenteric 

glands, 654 
in variola, 751 

in typhoid fever, 777, 778, 781 
in cases of worms, 876, 877 
Abscess of leg simulating rheumatism, 32 
of lung following pneumonia, 159 
bronchial, in bronchitis, 193 
iliac, in disease of coecum and appen- 
dix. 405, 409 
verminous, 876 
Absorbents in entero-colitis, 367 
Acarus scabiei, description of, 831 
Achorion Schoenleinii, the fungus of fa- 

vus, 849 
Acids in local treatment of gangrene of 
the mouth, 283 
carbolic, in gangrene of the mouth, 
286 
in diphtheria, 623 
in scabies, 833 
in favus, 838 
muriatic, in gangrene of the mouth, 
286 
in diphtheria, 622 
in scarlatina, 709 
sulphuric, in chronic entero-colitis, 
376 
^Egophony in pleurisy, 213 
Affusion, cold, in scarlatina, 711 

warm, in mild cases of scarlatina, 
707 
Air, as injection in intussusception, 432 
Albuminuria, in pneumonia, 175 
in diphtheria, 612, 616 
during desquamation in scarlatina, 

676 
in scarlatinous dropsy, 697 
in variola, 752 
in typhoid fever, 781, 783 
Alkalies in membranous croup, 101 
in thrush, 309 
in rheumatism, 594 
local use of in diphtheria, 623 
in skin diseases, 857, 861 



Alopecia Areata. 

article on, 864 

frequency of, 864 

fungous nature of, doubtful, 850, 864 

contagion as cause of, 864 

symptoms of, 864 

condition of hairs in, 864 

baldness following, 864 

diagnosis of, 864 

prognosis in, 865 

treatment of, 865 
Alum, as an emetic in true croup, 99 

in hooping-cough, 244 
Amaurosis, after diphtheria, 619 

Anaesthetics. 

use of during tracheotomy, 118 
in eclampsia, 509 
in tetanus, 545 
Analysis of cow's milk, 298 
of human milk, 306 
of fluid in hydrocephalus, 485 
of bones in rickets, 640 
of fluid in sclerema, 868 

Anatomical Lesions. 
in coryza, 53 

in simple spasmodic laryngitis, 70 
in pseudo-membranous laryngitis, 88 
in congenital atelectasis, 131 
in collapse of the lung, 141 
in pneumonia, 157 
in bronchitis, 191 
in pleuris3 T , 212 
in hooping-cough, 239 
in cyanosis, 252-256 
in acute pericarditis, 262 

endocarditis, 262 
in chronic valvular diseases, 263 
in gangrene of the mouth, 277, 288 
in thrush, 289 
in simple pharyngitis, 310 
in simple diarrhoea, 328, 329 
in gastritis, 337 
in entero-colitis, 349 
in cholera infantum, 383 
in dysentery, 400 
in diseases of coecum and appendix, 

409 
in intussusception, 420 



890 



INDEX. 



Anatomical lesions in tubercular menin- 
gitis, 438 

in simple meningitis, 465 

in cerebral hemorrhage, 477 

in chronic hydrocephalus, 484 

in eclampsia, 502 

in laryngismus, 514 

in tetanus nascentium, 540 

in chorea, 550 

in atrophic infantile paralysis, 577 

in progressive paralysis, with appar- 
ent hypertrophy of muscles, 590 

in diphtheria, 601 

in mumps, 629 

in rickets, 639 

in bronchial phthisis, 643 

in pulmonary phthisis, 644 

in tuberculous peritonitis, 645 

in tuberculosis of mesenteric glands, 
646 

in scarlatinous dropsy, 693 

in scarlatina, 699 

in measles, 737, 738 

in typhoid fever, 776 

in sclerema, 868 

in ascaris lumbricoides, 875 

Anderson, McCall. 

on parasitic skin diseases, 851 

Angina ; see Pharyngitis. 

in diphtheria, 606 

in scarlatina, 675, 683, 717 
Antimony in catarrhal croup, 81 

in pneumonia, 182 

in capillary bronchitis, 206 

excessive action of, in children, 183, 
206 

in pleurisy, 221 
Antiseptic remedies in scarlatina, 710 
Antispasmodics in eclampsia, 508 

in laryngismus stridulus, 524 

in tetanus, 545 

in chorea, 563 

Aphthae ; see Follicular Stomatitis. 

fatty nature of deposit in, 270 
Apoplexy ; see cerebral hemorrhage, 475 
Apparatus, mechanical, in infantile paral- 
ysis, 584 

Appendix Cceci. 

catarrhal inflammation of, 409 
perforative ulceration of, 414 
article on diseases of ccecum and ap- 
pendix, 404-419 

age as cause, 406 

sex as cause, 407 

intestinal concretions as cause, 407 

anatomical lesions of, 409 

cases of, 410 

symptoms of, 414 

duration of, 415 

prognosis in, 415 

diagnosis of, 416 
diseases of, treatment of, 418 



Arsenic in chorea, 564, 565 

in eczematous affections, 819 

Artificial food for children, 279-307 
as cause of indigestion, 317 

Ascaris Lumbricoides. 

article on, 873-885 

description of, 870 

synonymes of, 870 

early age as cause of, 873 

disposition to, hereditary, 874 

seat of, 874 

number of, 874 

anatomical lesions in, 875 

condition of mucous membrane in, 
875 

perforation of intestine, by, 875 

hemorrhage from bowel in, 877 

verminous abscesses in, 876 

no diagnostic symptoms of, 876 

digestive disturbances caused by, 876 

restlessness caused by, 877 

peculiar physiognomy, caused by, 877 

mechanical effects of, 877 

effects caused by displacement or mi- 
gration of, 878 

dyspnoea and cough caused by, 878 

nervous symptoms caused by, 879 

diagnosis of, 879 

prognosis in, 880 

treatment of, 880-885 

caution in use of vermifuges, 880 

wormseed-oil in cases of, 881 

pinkroot in cases of, 881 

turpentine in cases of, 882 

calomel in cases of, 882 

santonine in cases of, 883 

kameela in cases of, 884 

general treatment in cases of, 884 

treatment of complications in cases 
of, 884 

diet in cases of, 885 

Ascaris Yermicularis. 
article on, 885-887 
description of, 871 
synonymes of, 871 
seat of, 885 
causes of, 885 
symptoms of, 885 
diagnosis of, 885 
prognosis in, 886 
treatment of, 886 
enemata in treatment of, 886 
ointments in treatment of, 887 
Assafcetida in chorea, 564 
Astringents in entero-colitis, 367, 374 

local use of, in diphtheria, 623 
Ataxia, locomotor after diphtheria, 621 
Atelectasis pulmonum, and collapse of the 
lung, 131-153 
peculiarity of respiration in, 41, 

134 
forms of, 131 

congenital, anatomical appear- 
ances in, 131 



INDEX. 



891 



Atelectasis pulmonum, congenital, causes, 
132 
symptoms of, 133 
in early weeks of life, symptoms 

of (see collapse), 134 
diagnosis of, 136 
prognosis of, 137 
treatment of, 137, 138, 139 

effects of position in, 138 
post-natal (see collapse of lung), 

139 
as cause of sclerema, 866, 869 
Atmospheric pressure as cause of deformi- 
ties in rickets, 637 
Atrophy, muscular (see infantile paraly- 
sis), 569 

ArSCTJLTATTON - . 

of heart, 36 

of lungs, 42, 43, 44 

best position of child in, 43 
in true croup, negative results of, 93, 

112, 129 
in pneumonia, 164, 167, 170 
in bronchitis, 195, 197, 199, 200 
in pleurisy, 213 

of heart in chorea, 551, 552, 556 
in bronchial phthisis, 649 
in pulmonary phthisis, 649 
of head in rickets, 635 



Barthez. 

results of expectant treatment in 
pneumonia, 178, 180 

Baths. 

in treatment of cholera infantum, 398 
in treatment of skin diseases, 829, 846 
cold, as prophylactic in catarrhal 
croup, 84 
in treatment of chorea, 566 
in grave cases of scarlatina, 711- 
716 
hot, in treatment of scarlatinous drop- 
sy, 720 
sulphurous, in treatment of tetanus, 

566 
warm, in treatment of catarrhal croup, 
80,82 
in eclampsia, 506 
in tetanus, 546 
in mild cases of scarlatina, 

707 
in rubeola, 742 
in variola, 757 
Becquerel, pulse in children, 34 
Belladonna, in catarrhal croup, 82 
in hooping-cough, 242, 245 
in tetanus, 545 
in infantile paralysis, 582 
as prophylactic in scarlatina, 721 
Benedict, case of laryngismus stridulus, 

525 
Bennett, J. Hughes, restorative treat- 
ment of pneumonia, 180 



Bennett, J. Hughes, on bleeding in treat- 
ment of pneumonia, 182 
Berg, fungous nature of thrush, 288 
Billard, pulse in children, 33 
Bird, Golding, alum in hooping-cough, 244 
Bismuth, subnitrate of, in entero-colitis, 

368 
Blebs (see Bullae), 834 
Bleeding, in severe spasmodic simple la- 
ryngitis, 81 
in pseudo-membranous laryngitis, 97 
in pneumonia, 179 
in bronchitis, 205 
in pleurisy, 221 
in hooping-cough, 241 
in gastritis, 341 
in typhlitis, 417 
in intussusception, 431 
in tubercular meningitis, 455 
in simple meningitis, 470 
in eclampsia, 506 
in tetanus, 545 

in atrophic infantile paralysis, 582 
in scarlatina, 708 
in rubeola, 742 
in variola, 758 
Blisters, mode of using, in children, 184 
in pneumonia, 184 
in pleurisy, 223 
Blood, condition of, in scarlatina, 700 
in measles, 738 
in variola, 755 
in typhoid fever, 776 
Bloodvessels of skin in sclerema, 868 
Bloody stools in intussusception, 425, 430 
Bones, alterations of, in rickets, 639 

disease of, in congenital syphilis, 662 
Bothriocephalus latus, 872 
Bouchut, pulse in children, 34 

expectoration in pneumonia, 172 
stools in entero-colitis, 356 
Brain, condition of, in tubercular menin- 
gitis, 440 
in simple meningitis, 466 
congestion of (see cerebral conges- 
tion), 471 
condition of, in cerebral hemorrhage, 
477 
in tetanus, 540 
in chorea, 552 
in congenital syphilis, 662 
in scarlatina, 699 
in typhoid fever, 777 
Bretonneau, on nasal diphtheria, 610 

Bronchia. 

dilatation of, in capillary bronchitis, 
192 
in chronic bronchitis, 195 
physical signs of, 200 
Bronchial abscess, in bronchitis, 193 
glands, tuberculosis of, 643, 647 
phthisis (see tuberculosis of bronchial 
glands) 
Bronchitis, connection of, with atelecta- 



892 



INDEX. 



Bronchitis in typhoid fever, 782, 783 

in hooping cough, 237, 239 

in measles, 732^ 734 

frequency and mortality of, 153, 157, 
189 

effect of temperature and season upon 
mortality of, 157 

article on, "188-211 

definition of, 188 

synonymes of, 188 

forms of, 189 

predisposing causes of, age, sex, sea- 
son, insufficient clothing, 189 

exciting causes, 190 

anatomical alterations in, 191 
in acute ordinary form, 192 
in capillary form, 192 

dilatation of bronchia in, 192 

bronchial abscess in, 193 

condition of lung tissue in, 194 

lesions in chronic form, 195 

symptoms of simple acute form, 195 

aggravation of symptoms at night, 
196 

duration of simple acute form, 196 

danger of collapse of lung in, 196 

symptoms of capillary form, 197 

duration of capillary form, 198 

symptoms and course of chronic form, 
198 

physical signs in, 199 

cough in, 200 

peculiar cough in capillary form, 200 

respiration and pulse in, 201 

urine in, 202 

diagnosis of, 202 

peculiarity of dyspnoea in, 203 

prognosis in, 203 

treatment of, 21)4-211 

importance of confinement to bed, 204 

bleeding in, 205 

emetics in, 206 

antimony in the capillary form, 206 

ipecacuanha in, 207 

external applications, cups, in, 207 

use of stimulants in, 208 

use of quinia in, 208 

treatment of chronic form, 210 
Bullae, chapter on, 834 



Calomel (see mercury), use in spasmodic 
croup, 81 
use in diarrhoea, 365 

cholera infantum, 398 
tubercular meningitis, 459 
simple meningitis, 470 
chronic hydrocephalus, 491 
eczematous affections, 820 
as a vermifuge, 882 
Cannabis Indica in tetanus, 545 

Canula for Tracheotomy. 

details of size and form, 115 
Capillary bronchitis (see bronchitis) 188- 
211 



Carbolic Acid ; see Acid. 
Carpo-pedal spasms, 530 

in laryngismus stridulus, 519 

Cases, Illustrative. 
of chronic coryza, 60 
of pseudo-membranous laryngitis, 124 
of collapse of the lung, 135, 147 
of cerebral pneumonia, 176 
of chronic pleurisy, 228 
of cyanosis, 254, 259 
of cardiac disease, 265 
of perforation of appendix coeci, 410 
of tubercular meningitis, 442 

apparent recovery from, 452, 
462 
of laryngismus stridulus, 525 
of contraction with rigidity, 532 
of atrophic infantile paralysis, 573 
of heart-clot in diphtheria, 618 
of mode of invasion of scarlatina, 678, 

682 
of grave form of scarlatina, 687 
of croup in, 690 
of convulsions in, 704 
of use of cold lotions in, 714 
of use of ice in angina of, 717 
of convulsions in measles, 727 
of fatal serous effusion in, 736 
fatal, of measles, 739 
of tinea, 862 

Catarrh of stomach and intestines (see 
indigestion), 316 
of stomach, 338 
in measles, 726 

Cauterization of variolous pock to prevent 
pitting, 759 

Cavities, tuberculous, 644, 645 

Cerebral Congestion, article on, 471- 
475 
of less importance than usually con- 
sidered, 471 
"West's views on, 473 
causes of, 473 
division into active and passive forms, 

473 
symptoms of, 473 
terminations of, 474 
treatment of the two forms, 475 
Cerebral disease in congenital syphilis, 662 
Cerebral form of pneumonia, 176 
Cerebral hemorrhage, article on, 475-483 
definition and frequency, 475 
forms of, cerebral and meningeal, 

475, 476 
causes of, 476 
anatomical lesions of, 477 

of the meningeal form, 477 
transformation of the clot in, and for- 
mation of pseudo-cyst, 478 
symptoms of cerebral form, 479 

meningeal form, 480 
chronic hydrocephalus following me- 
ningeal form, 481, 486 
duration of, 481 






INDEX. 



893 



Cerebral hemorrhage, diagnosis of cere- 
bral form, 482 
meningeal form, 482 
treatment of, 482 
depletion in, 482 

cold and counter-irritation in, 483 
treatment of paralysis following, 483 
chronic hydrocephalus following, 
483 
Cerebral symptoms, in pneumonia, 173 
in bronchitis, 201 
in cholera infantum, 389 
in intussusception, 427 
in tubercular meningitis, 443, 447 
in simple meningitis, 467 
in cerebral congestion, 474 
in cerebral hemorrhage, 479 
in chronic hydrocephalus, 488 
in laryngismus stridulus, 519 
in contraction with rigidity, 531 
in chorea, 5-56 

absence of in atrophic infantile pa- 
ralysis, 572 
in mumps, 631 
in scarlatina, 075, 678 
in measles, 735, 744 
in variola, 752 

in typhoid fever, 777, 779, 782, 787 
caused by worms, 879 
Chambers, T. K.,on poultices in pneumo- 
nia, 185 
Chemical characters of false membranes, 

603 
Chenopodium, oil of, in treatment of 

worms, 881, 886 
Chicken-pox; see Varicella. 
Chloroform in eclampsia, 509 
in laryngismus, 525 

Cholera Infantum, article on, 378-399 
general remarks on, 378 
definition and synonymes of, 379 
frequency of, 379 
causes of, 380 

great heat as a cause of, 380 
improper diet as a cause of, 381 
hygienic conditions favorable to, 381 
anatomical appearances and patholo- 

gy of, 383 
symptoms of, 387 
character of stools in, 387 

of vomiting in, 388 
course and duration of, 389 
diagnosis of, 390 
prognosis in, 390 
prophylactic treatment in, 391 
treatment of stage of evacuation, 392 

of stage of collapse, 394 
importance of free supply of water in, 

394 
mistura indica in, 395 
importance of rest in, 396 
treatment of stage of reaction, 396 
importance of attending to state of 

gums in, 397 
use of baths in, 398 



Cholera infantum, use of calomel in, 398 

Chorea, article on, 546-569 

definition and synonymes of, 546 
frequency of, 547, 561 
early age as predisposing cause, 547 
other predisposing causes of, 547 
rheumatism as cause of, 548 
fear and other exciting causes of, 550 
anatomical lesions in, 550 
lesions of heart in, 551 
brain in, 552 
spinal cord in, 552 
microscopical changes in spinal cord 

in, 553 
portions of body affected in, 553 
prodromic symptoms of, 553 
symptoms of invasion of, 554 

of the confirmed disease, 554. 556 
respiratory muscles and heart at times 

affected, 555 
paralysis of sphincters in, 5">5 
loss of voluntas power in, 555, 572 
general symptoms in, 556 
condition of urine in, 556 
cardiac murmurs in, 556 
course of, 556 
effects of acute intercurrent disease 

upon, 556 
duration of, 556 
frequency of relapses, 556 
nature of, 557 

probable seat of lesion in, 557 
alterations of blood as cause of, 558 
reflex irritation as cause of, 558 
embolism as cause of, 263, 559 
mode of action of rheumatism as 

cause of, 560 
prognosis in, 560 
statistics of mortality in, 561 
unfavorable symptoms in, 561 
duration of, 561 
treatment of, 562 
use of purgatives in, 562 
antispasmodics in, 563 
cimicifuga in, 563 
arsenic in, 564 
strychnia in, 565 
conium in, 565 
stimuli in, 565 
baths in, 566 

gymnastic exercises in, 567 
hygienic treatment of, 569 
Chronic bronchitis, 198 

pleurisy, 217 
Cimicifuga racemosa in chorea, 563 
Circulatory organs, diseases of, 252 
Clarke, J. L., state of spinal cord in teta- 
nus, 542 
in chorea, 553 
Clinical examination of children, 17 
Club-foot, in infantile paralysis, 575 
Cod-liver oil, in habitual indigestion, 325 
in ricUets, 642 
in tuberculosis, 657 
in eczematous affections, 820 



894 



INDEX. 



Ccecum and appendix coeci, article on dis- 
eases of, 404—419 
(Seesdso typhlitis, perityphlitis, and ap- 
pendix ) 
Coecum and appendix, diseases of, syno- 
nymes and definition of, 404 
seat and character of, 405 
causes of, 406 

intestinal concretions as cause of, 407 
anatomical lesions in, 409 
illustrative cases of, 410 
symptoms of, 412 
duration of, 415 
prognosis in. 415 
diagnosis of, 415 
treatment of, 417 
Ccecum, symptoms of fecal distension of, 
412 
perforative ulceration of, 414 
inflammation of (see typhlitis) 
Cold, as cause of dropsy after scarlatina, 693 
applications in tubercular meningitis, 
458 
in simple meningitis, 470 
in eclampsia, 507 
in laryngismus stridulus, 524 
in tetanus, 546 
in scarlatina, 711-716 

Collapse oe Lung. 

in bronchitis, 196, 200 

in hooping cough, 236 

in rickets, 640 

article on, 131-153 

in early weeks of life, svmptoms of, 

134 
cyanosis in, 134 
diagnosis of, 136 
prognosis of, 137 
or post-natal atelectasis, 139-153 
general remarks on and pathologv of, 

139, 140, 141 
identity of lobular pneumonia with, 

140 
anatomical lesions in, 141 
congestion of lung accompanying, 142 
differences between condition of lung 

in, and in pneumonia, 142 
portions of lung affected in, 143 
causes of, and explanation of mode of 

production, 144 
symptoms of, 146 
diagnosis of, 149 
prognosis of, 150 
treatment of, 150 
use of emetics in, 151 
treatment of when combined with 

bronchitis, 152 
Coloration of skin, significance of changes 

of, 22 
in infants, 30 
of face in pneumonia, 173 
Colostrum corpuscles, 307 
Compression of head in hydrocephalus, 491 
Concretions, intestinal, 407-409 
Condylomata in congenital syphilis, 611 



Congenital Syphilis ; see Syphilis. 
Congestion of the brain (see cerebral con- 
gestion), 471 
Congestion of the lungs, non-inflamma- 
tory, 159 
in bronchitis, 194 
in typhoid fever, 782 
Conium in tetanus, 546 

in chorea, 565 
Constipation, as cause of diseases of the 
coecum, 413 
in intussusception, 425 
Constitutional diseases, 591 
Contagion of hooping-cough, 231 
of diphtheria, 598 
of mumps, 628 
of scarlatina, 668 
of rubeola, 724 
of small-pox, 747 
of varicella, 773 
of tvphoid fever, 776 
of favus, b52 
of tinea, 858 
of alopecia areata, 864 
Contraction, with rigidity, article on, 529- 
538 
a rare affection, 529 
definition of, 529 
causes of, 529 
nature of, one of the forms of 

eclampsia, 529 
symptoms of, 530 
carpo-pedal spasms in, 530 
diagnosis of, from symptomatic 

contraction, 531 
prognosis in, 532 
treatment of, 532 
case by Dr. J. F. Meigs, 532 
Contracture; see Contraction. 

Convulsions, General, or Eclampsia, 
article on, 493-511 

general remarks on ; forms of, 493 

definition, synonyines, frequen- 
cy, 494 

causes of, 494 

most frequent before age of seven 
years, 494 

nervous temperament as a pre- 
disposing cause of, 495 

hereditary nature of, 496 

exciting causes of, 496 

frequency of different forms of, 
497 

prodromic symptoms of, 497 

symptoms of the attack, 498 
partial, varieties of, 499 
general, duration of, 499 

nature of, 500 

M. Hall's views on spasm of the 
larynx, 501 

centric and eccentric causes of, 501 

no lesion as yet detected in, 502 

diagnosis of from epilepsy, 503 
"the form of convulsion, 503 

prognosis in, 504 



INDEX. 



895 



Convulsions, general, treatment of, 505 

importance of discovering cause 

of attack, 506. 510 
treatment of attack, 506 
bleeding in, 506 
emetics in, 507 
antispasmodics and opium, in, 

503, 509 
chloroform in, 509 
internal, definition of, 519 

symptoms of paroxysm, 520 
degree of laryngismus present, 

510 
incomplete, or holding-breath 

spells, 520 
rarely dangerous, 521 
in pneumonia, 173, 174 
in hooping-cough, 233 
in tubercular meningitis, 446 
in simple meningitis, 466 
in meningeal apoplexy, 480, 481 
in scarlatina, 680, 704 
uraemic, in scarlatina, 696 
in initial stage of measles, 727 
in later stages of measles, 733, 739, 745 
in typhoid fever, 783 
in worms, 879, 885 
Corson, cold affusions in scarlatina, 713 
Coryza, definition, synonymes, forms, fre- 
quency, 52 
causes of, 53 

anatomical lesions in, 53 
symptoms of mild form, 53 

of severe form, 54 
duration of, 55 
prognosis in, 55 

in the course of other diseases, 56 
chronic, symptoms and duration of, 56 
treatment of acute. 57 
local, of acute, 58 
of chronic, 58 
case of chronic, 60 
in congenital syphilis, 660 
in scarlatina. 685 
Cough, in simple laryngitis, 63 

violent in chronic laryngitis, 64 

in true croup, 92 

in pneumonia, 171 

in pleurisy, 216 

in hooping-cough, 232, 234,239 

in spasmodic simple laryngitis, 72, 

73, 75 
in bronchial phthisis, 648 
in pulmonary phthisis, 650 
in measles, 729, 733 
in typhoid fever, 782, 783 
Countenance, alterations of, 21 
Counter-irritation in tubercular menin- 
gitis, 458 
in simple meningitis, 471 
in chorea, 566 
in scarlatinous dropsy, 720 
in pulmonary complications of mea- 
sles, 743 
Country residence, importance of in sum- 
mer, 361, 391 



Country residence, importance of in tuber- 
culosis, 656 
Cowhage as a vermifuge, 883 

Cow-Pox; see Vaccine Disease. 
Cracked-pot sound in bronchial phthisis, 

649 
Cream, proportion of in cow's milk, and 
mode of determining, 299 
in human milk, 306 
Croup, diphtheritic, 608 

relations of to pseudo-membranous 

laryngitis, 84, 608 
false, spasmodic, or catarrhal (see 

spasmodic simple laryngitis), 68 
true or membranous (see pseudo-mem- 
branous laryngitis), 84 
secondary, in scarlatina, 689 
tracheotomy in, 113 
Crust, vaccine, characters of, 769 
Crusta lactea (see eczema capitis), 812 
Cry, characters of the, 24 

peculiar in meningitis, 444 
alterations of in simple laryngitis, 63 
peculiar in sclerema, 867 
Crystalli ; see Varicella. 
Currie, cold affusions in scarlatina, 711 
Cutaneous diseases, 789 

not transmitted by vaccination, 768 
Cutaneous diphtheria, 610 

surface, signs from, 22, 30 

Cyanosis, in collapse of the lung, 134 
article on, 252-260 
definition of, 252 
anatomical appearances in, 252 
illustrative cases of, 254 
theories of mode of production of, 256 
symptoms of, 257 
date of appearance of lividity, 257 
modes of death in, 258 
duration of life in, 258 
illustrative case of, 259 
treatment of the form due to atelec- 
tasis, 259 
of paroxysms of dyspnoea, 260 
hygienic treatment, 260 
effect of position on, 260 
neonatorum, Prof. Meigs on treat- 
ment of, 138 

Cynanche Parottdea; see Mumps. 
Cyst, pseudo-, in arachnoid in meningeal 

apoplexy, 478 
Deafness after diphtheria, 619 
Decubitus of children, 28 
in different diseases, 29 
in tubercular meningitis, 448 
Deformities in rickets, 636 
Deglutition, difficulty of in bronchial 
phthisis, 648 
in scarlatina, 683 
Dentition as cause of entero-colitis, 349 
of cholera infantum, 382 
of eclampsia, 510 
of laryngismus stridulus, 513 



896 



INDEX. 



Dentition as cause of infantile paralysis, 
571 

impeded in rickets, 635 
Desiccation in variola, 750, 751 
Desquamation in scarlatina, 676 

in measles, 729 

in small-pox, 751 

in varicella, 774 

in erysipelas, 797 
Development, degree of as aid in diag- 
nosis, 27 

Diagnosis in children, difficulties of, 18 

general method of, 19 

of simple laryngitis without spasm, 65 

of spasmodic simple laryngitis from 
true croup, 75 
from laryngismus stridulus, 
521 

of pseudo-membranous laryngitis, 75 
95, 96 

of catarrhal from true croup, 75, 96 

of idiopathic from diphtheritic croup, 
85, 86, 95 

of true and false croup from laryngis- 
mus stridulus, 136, 150 

of atelectasis from pneumonia, and 
pleurisy, 150 

of collapse of the lung, 149 

of pneumonia from bronchitis, pleu- 
risy, &c, 175-177 

of cerebral pneumonia from cerebral 
disease, 176, 177 

of bronchitis from pneumonia, 202 
from hooping-cough, 202 

of pleurisy from pneumonia, 219 

in early stage from one of the 
exanthemata, 220 

of hooping-cough from acute bron- 
chitis, 238 
from tu berculosis df the bronchial 
glands, 238 

of aphthae from ulcero-membranous 
stomatitis, 270 

of ulcerative stomatitis from gan- 
grene of the mouth, 281 

of thrush, 296 

of simple pharyngitis, 313 

of indigestion, 320 

of simple diarrhoea, 331 

of gastritis, 340 

of entero-colitis, 3G0 

of cholera infantum, 390 

of dysentery, 401 

of diseases of ccecum and appendix, 
415, 430 

of intussusception, 429 

of tubercular meningitis, 449 

of simple meningitis, 469 

of cerebral congestion, 469 

of cerebral hemorrhage, 482 

of chronic hydrocephalus, 489 

of eclampsia, 503 

of laryngismus stridulus, 136, 521 

of contraction with rigidity, 531 

of tetanus nascentium, 544 



Diagnosis of atrophic infantile paralysis, 

581 
of facial paralysis, 586 
of progressive paralysis with apparent 

hypertrophy of the muscles, 590 
of acute rheumatism, 593 
of diphtheria, 615 
of mumps, 631 
of rickets, 639 
of tuberculosis, 654 
of tuberculous peritonitis, 655 
of tuberculosis of mesenteric glands, 

655 
of congenital syphilis, 662 
of scarlatina, 700 
of rubeola notha, 702 
of rubeola, 738 
of variola, 756 
of vaccine disease, 766 
of varicella, 774 
of typhoid fever, 785 
of erythema fugax, 790 
of erythema, 792 
of erysipelas, 798 
of roseola, 8)4 
of urticaria, 808 
of eczematous affections, 816 
of herpes, 8-8 
of scabies, 831 
of pemphigus, 835,838 
of rupia, 838, 840 
of ecthyma, 840 
of strophulus, 842 
of lichen, 844 
of prurigo, 845 
of favus, 854 
of tinea tonsurans, 860 
of tinea circinata, 861 
of alopecia areata, 864 
of sclerema, 868 
of ascaris lumbricoides, 879 
vermicularis, 885 

Diaphoretics ; see Formulas. 

hot bath as, in scarlatinous dropsy, 721 
Diarrhoea in thrush, 293 

simple or catarrhal, article on, 326- 
335 
nature of, 326 
causes of, 326 

improper diet as a cause, 327 
anatomical lesions in, 328 
symptoms of, 329 
course of, 331 
diagnosis of, 331 
prognosis in, 331 
treatment of, 332 

of chronic form, 334 
inflammatory [see entero-colitis), 342 
in rickets, 635 

in tuberculous peritonitis, 653 
in tuberculosis of mesenteric glands, 

654 
in scarlatina, 698 
in measles, 734, 735, 744 
in variola, 751, 759 



INDEX. 



897 



Diarrhoea in typhoid fever, 777, 781, 787 
Diday, on infantile syphilis, 659 
Diet (see also food), in pneumonia, 185, 187 
after tracheotomy, 122 
in chronic bronchitis, 210 
in pleurisy, 221 
in thrush, 307 

after premature weaning, 297-307 
in indigestion, 323 
improper, as cause of indigestion, 317 

as cause of diarrhoea, 327 
proper in diarrhoea, 332, 334 
in gastritis, 311 

in acute entero-colitis, 363, 370 
in chronic entero-colitis, 372 
improper as cause of cholera infan- 
tum, 380 
suitable for children, 297, 391 
in tubercular meningitis, 456, 461 
in laryngismus stridulus, 522 
in diphtheria, 626 
in rickets, 641 
in tuberculosis, 657 
in congenital syphilis, 663 
in scarlatina, 707 
in rubeola, 741 
in variola, 758 
in typhoid fever, 788 
as cause of urticaria, 806 
in urticaria, 808 
in rupia, 838 
in ecthyma, 841 
in ascaris vermicularis, 885 
Digestive organs, diseases of, 268 

disturbances in early stage of rickets, 
635 
in tuberculous peritonitis, 652 
in tuberculous of mesenteric 

glands, 654 
in variola, 751 

in typhoid fever, 777, 778, 780 
in erythema intertrigo, 791, 794 
caused by worms, 876 
Digitalis in scarlatinous dropsy, 720 
Dilatation of bronchia, 192, 193 
Diphtheria, article on, 596-628 

definition and synonymes of, 596 
history of, 596 

statistics of frequency, 597, 599 
epidemic, contagious, and infectious 

nature of, 597 
influence of season upon, 598 
table showing monthly mortality, 

599 
influence of age upon, less than in 

croup, 600 
nature of: a constitutional disease, 600 
pathological anatomy of, 601-606 
development of false membranes, 601, 

602 
color and consistence of false mem- 
branes, 602 
microscopic anatomy of false mem- 
branes, 603 
chemical characters of false mem- 
branes, 603 



Diphtheria, condition of mucous mem- 
brane in, 603, 604 
lesions in croup following, 604 
seat of exudation in, 604, 605 
exudation on skin in, 605 
condition of submaxillary glands in, 

605 
fatty degeneration of heart in, 605 
condition of kidneys in, 605 
lesions in secondary form, 606 
forms of, 606 
S} T mptoms of, 606 
condition of throat in, 606, 607 
difficulty in deglutition not constant, 

607 
danger of exudation extending to la- 
rynx, 608 
symptoms of croup in, 609 
nasal variety of, 610 
cutaneous, symptoms of, 610 
invasion often insidious, 611 
general symptoms of mild form, 611 

of severe form, 612 
urine in, 612 
eruption in, 613 
course in fatal cases, 613 
malignant symptoms in, 613 
duration of, 614 
prognosis in, 614 
diagnosis of, 615 

from scarlatina, 615 
albuminuria in, 616 
heart-clot in, 617 

Richardson's account of symp- 
toms of, 617 
cases of, 618 
endocarditis in, 618 
paralysis following, 619 

order of muscles affected in, 619 
motion and sensation both af- 
fected, 620 
result usually favorable, 620 
explanation of, 620 
locomotor ataxia following, 621 
treatment of, 621-628 
local applications to throat in, 621 
solvents for the false membranes, 623 
use of gargles in, 624 
local use of ice in, 624 
external applications in, 625 
injections in nasal form of, 625 
general treatment of, 625 
necessity for supporting remedies, 625 
stimulants in, 626 
diet in, 626 

necessity for absolute rest, 627 
treatment of the paralysis after, 627 
of heart-clots, 629 
Diuretics {see formulas), in scarlatinous 

dropsy, 720 
Dress, suitable for children, 83, 362, 391 

insufficient, as cause of pneumonia, 190 
Drinks, manner of taking as a diagnostic 

sign, 49 
Dropsy, after scarlatina (see article on 
scarlatina), 691-698 



57 



898 



INDEX. 



Dropsy, after scarlatina, treatment of, 
719-721 

after measles, 736 
Duchenne, on progressive paralysis, 589 
Dysentery article on, 399-404 

causes of, 399 

anatomical lesions of, 400 

symptoms of, 400 

diagnosis of, 401 

prognosis in, 401 

treatment of, 401 



Earache, violent crying in, 25 
Eclampsia (see convulsions), 493 
Ecthyma, article on, 839-841 

definition, synonymes, varieties, 839 
causes of, 839 

diagnosis of, from rupia, 838, 840 
prognosis in, 840 
general treatment of, 841 
local treatment of, 841 
vulgare. 

symptoms of, 840 
infantile. 

symptoms of, 840 
Eczematous affections, article on, 809-824 
definition of, 809 
elementary lesions in, 809 
eruption frequently mixed in, 810 
seats of eruption in, 8L0 
forms of, 810 
causes of, 810 
diagnosis, 816, 832 
prognosis in, 817 
no danger in curing quickly, 817 
principles of treatment of, 818 
general treatment in, 818 
attention to digestive symptoms in, 818 
.use of arsenic in, 819 

of codliver oil in, 820 
of iron in, 820 
of calomel in, 820 
local treatment of, 820-824 
cool and emollientapplicationsin,820 
benzoated oxide of zinc ointment in, 

821 
mode of removing crusts in, 821 
lotions in, 822 
ointments in, 823 
spiritus saponatus kalinus of Hebra 

in, 823 
solutions of potash in, 823 
tarry applications in, 824 
use of soaps in, 823, 824 
mercurial applications in, 824 
eczema simplex. 
symptoms of, 811 
diagnosis of from scabies, 817, 832 
from sudamina, 817 
eczema papillosum. 

symptoms of, 811 
eczema pustulosum ; or impetiginoid.es. 
symptoms of, 811 
diagnosis from favus, 817 
prognosis in, 817 



Eczematous affections 
eczema capitis. 
symptoms of, 812 
condition of scalp in, 813 
chronic form of, 813 
mode of removing crusts in, 821 
eczema faciei. 

symptoms of, 813 
eczema larvale. 

general symptoms in, 814 
duration of, 815 
eczema granulatum. 
symptoms of, 814 
eczema tarsi. 

symptoms of, 815 
treatment of, 824 
impetigo figurata, 815, 816 

sparsa, 816 
eczema chronicum. 

common to all varieties, 816 
symptoms of, 816 
seats of, 816 
duration of, 817 
general treatment of, 819 
local treatment of, 821 
Electrical batteries, 584 
Electricity, in chorea, 567 

in infantile paralysis, 576, 583 
in facial paralysis, 587 
in progressive paralysis, 589 
in diphtheritic paralysis, 627 
Electro-muscular contractility in infan- 
tile palsy, 573, 576, 577 
in facial palsy, 587 
in progressive palsy, 589 
Embolism in endocarditis as cause of 

chorea, 263, 559, 560 
Emetics, in catarrhal croup, 79, 82 
in membranous croup, 98 
in collapse of the lung, 151 
in bronchitis, 206 
in hooping-cough, 243 
in eclampsia, 507 
in diphtheria, 626 
Emphysema, association with pneumonia, 

162 
Empyema, symptoms and course of (see 
pleurisy), 218 
paracentesis in, 225 
Empvreumatic oil of Chabert as a vermi- 
fuge, 883 
Endocarditis, in diphtheria, 618 
in scarlatina, 699 
acute, 262, 263 

symptoms of, 262 
prognosis in, 263 
anatomical appearances, 263 
embolism in, in connection with 

chorea, 263 
treatment of, 263 
Enemata, astringent in chronic entero- 
colitis, 375 
in dysentery, 403 ■ 
in disease of coecum, 418 
of air and fluids in intussusception, 432 
in eclampsia, 508 






INDEX. 



899 



Enemata in treatment of worms, 886 
Enteritis in measles, 734 
in variola. 751, 759 
Entero-eolitis, article on, 342-878 
definition of, 342 
frequency of, 342 
improper food and intense heat as 

causes of, 343 
analogies to camp diarrhoea, 348, 353 
dentition and weaning as causes of,349 
anatomical lesions in, 349 
seat of disease in, 349 
condition of intestinal follicles in, 351 
lesions in chronic form, 352 
microscopic changes in intestine, 353 
condition of stomach in, 354 

of liver in, 354 
pathology of, 354 

symptoms of in acute form, 355, 359 
condition of stools in acute form, 356 

of abdomen in acute form, 357 
vomiting in acute form, 358 
erythema of buttocks in acute form, 

359 
duration of acute form, 359 
symptoms of chronic form, 359 
course and duration of chronic form, 

360 
diagnosis of, 360 
prognosis in, 360 
treatment of acute form, 361-371 

prophylactic, 361 
necessity for change of residence, 361 
importance of exercise in open air, 362 
diet in, 363 

therapeutical treatment of, 364 
use of calomel in, 365 
use of opium in, 366 
use of astringents and absorbents in, 
367 
of tonics and stimulants in, 369 
remedies for vomiting in, 371 
treatment of chronic form, 372-378 
diet in chronic form, 372 
use of raw meat in chronic form, 373 
nitrate of silver in, 374 
astringent enemata in, 375 
tonics and stimulants in, 377 
Epidemic nature of scarlatina, 669 
of rubeola, 723 
of variola, 746 
of varicella, 773 
of typhoid fever, 776 
of roseola, 803 
Epilation in favus, 856 

in tinea, 861 
Epistaxis in coryza, 57 

in bronchial phthisis, 648 
in typhoid fever, 782 
Ergot, in infantile paralysis, 582 
Eruption in diphtheria, 613 

in mild cases of scarlatina, 673,674 

in grave cases of scarlatina, 681, 686 

in measles, 728 

in malignant measles, 732 

in variola, 748-752 



Eruption in varioloid, 754 

in varicella, 773, 774 

in typhoid fever, 778, 782 

in erythema fugax, 790 
intertrigo, 791 
nodosum, 792 

in erysipelas, 797, 798 

in roseola, 803, 804 

in urticaria, 807. 808 

in eczematous affections, 810-816 

in herpes, 825, 826, 827 

in scabies, 830, 831 

in rupia, 837, 838 

in ecthyma, 840 

in strophulus, 842 

in lichen, 844 

in prurigo, 845 

in psoriasis, 846 

in pityriasis, 847 

in ichthyosis, 847 

in favus, 852-854 

in tinea, 859-860 
Eruptive fevers, 665 
Erysipelas, article on, 795-802 

definition and forms of, 795 

frequency of, 795 

causes of, 795 

following vaccination, 795 

epidemic and endemic nature of, 796 

starting-point of eruption, 796 

characters in very young infants, 796 

sloughing of skin in, 797 

characters of in older children, 797 

abscesses following, 798 

febrile symptoms in, 798 

typhoid symptoms in, 798 

duration of, 798 

diagnosis of, 798 

prognosis in, 798 

treatment of in young infants, 799 

local applications in, 800 

tr. ferri. chl. in, 801 

treatment of in older children, 801 

stimulants and tonics, in, 802 

local applications in, 802 
Erythema about anus in thrush, 295 

of buttocks, in entero-eolitis, 359, 
791 
' article on, 790-795 

definition and forms, 790 
fugax. 

symptoms of, 790 

diagnosis of from scarlatina, 790 
from erysipelas, 792 
from roseola, 793 
intertrigo. 

seat of eruption, 791 

character of eruption, 791 

ulceration in, 791 

form of occurring in connection with 
diarrhoea, 791 

prognosis in, 793 

treatment of, 793 

local applications in, 793 

attention to digestive derangement 



900 



INDEX. 



Erythema nodosum. 

symptoms of, 792 

diagnosis of from phlegmonous ery- 
sipelas, 793 

prognosis in, 793 

treatment of, 794 

tonics and stimulants in, 794 

local applications in, 795 
Essay, introductory, 17 
Essential convulsions (see convulsions). 
Essera (see urticaria), 806 
Examination clinical in children, 17 

difficulties of, 17, 18, 19 

of abdomen, 46 

of the heart, 35, 36, 37 

of mouth and fauces, 47 

of the pulse, 33, 34, 35 
Exercise, in open air, importance of, 362 
Expectoration, nummular, in measles, 729 

in true croup, 93 

in pneumonia, 171, 172 
Expiratory respiration in bronchitis, 201 
External applications (see local applica- 
tions). 



Facial paralysis (see paralysis). 
Eacies (see physiognomy). 
Ealse membrane, in croup, characters of, 
90 
in secondary croup, 91 
extent of and frequency with 
which bronchia are in- 
vaded, 88, 89 
action of chemical reagents upon, 

623 
in capillary bronchitis, 192 
in diphtheria, 601 



Ealse membrane in scarlatina, 683 
Fauces, examination of, 47, 48 

in membranous croup, 85, 89, 91 

in diphtheria, 606, 607 

in scarlatina, 675, 683 

in measles, 726 
Eavus, article on, 851-858 

definition and synonymes, 851 

varieties and frequency, 852 

description of the fungus which 
causes, 849 

contagion as cause of, 852 

occurs in lower animals, 852 

other causes of, 852 

symptoms of, 852 

nature of, 854 

diagnosis of, 854 

prognosis in, 855 

duration of, 858 

general treatment of, 855 

local treatment of, 856 

mode of removing crusts in, 856 

epilation in, 856 

parasiticides in, 857 
dispersus. 

eruption in, 852 



Eavus dispersus, course of, 853 
condition of hairs in, 853 
baldness following, 853 
seats of the eruption, 853 
confertus, 853 
eruption in, 854 
Eecal accumulation in coecum, svmptoms 
of, 412 
diagnosis of, 429 
as cause of eclampsia, 511 
Eevers eruptive, 665 
Eever, scarlet (see scarlatina), 665 

in variola, subsides on appearance of 

eruption, 750 
secondary in variola, 750 
typhoid, 775 

febrile action in, 780 
Finlayson, normal temperature in chil- 
dren, 38 
Follicles of intestine in entero-colitis, 351, 

353 
Eomites as means of transmitting scarla- 
tina, 689 
variola, 747 
Food, artificial, 297-307 

gelatine, for infants, 304 
Merei's, for infants, 305 
improper, as cause of indigestion, 317 
of diarrhoea, 327 
of entero-colitis, 343, 345 
of laryngismus stridulus, 513 
Foot-baths, in treatment of disease, 185, 
207, 757 

Formulary or receipts recommended. 

Alteratives. 
Formula for mixture of iodide of potassi- 
um and bichloride of mercury, 457 
Antacids and alkalies ; laxatives. 
Formula for mixture of soda, rhubarb, and 
paregoric, 308 
of magnesia and tr. thebaic, 308 
of sulphate of magnesia and rhu- 
barb, 333 
and laudanum, 334 
of soda, blue mass, and paregoric, 

364 
of crabs' eyes, 368 
for neutral mixture, 371 
of acetate and bicarb, potash and 
opium, 594 
Antiseptic. 
Formula for mixture of chlorinated lime, 
276 
Anthelmintics. 
Formula for mixture of ol. chenopodii, 881 
of spigelia, magnesia, and manna, 

882 
of ol. terebinth, and magnesia, 882 
of santonine, &c, 882 
Antispasmodics. 
Formula for pills of belladonna, opium, 
and valerian, 242 
for mixture of belladonna and opium, 
242 
of hydrocyanic acid, 243 



INDEX. 



901 



Astringents. 

Formula for mixture of alum and honey 
of roses, 269, 310 
of sulphate of copper and cincho- 
na, 275, 276 
of sulphate of copper and quinia, 

315 
for aromatic syrup of galls, 369 
of morph. sulph., and dil. sulph. 

acid, 371 
of soda, krameria, and opium, 819 
of nitrate of silver, 375 
solution of nitrate of silver, 375 

of pernitrate of iron and nitric 

acid, 376 
of aromatic sulph, acid, 376 

opium and krameria, 377 
of acetate of lead and acetic acid, 
393 
Febrifuges and diuretics [see also alka- 
lies). 
Formula for mixture of citrate of potash, 
ipecac, and paregoric, 81, 205 
of ipecac, opium, sp. aether, nitrosi, 

205 
of morphia, liq. ammon. acet., 207 
of iodide of potassium and sarsapa- 

rilla, 222 
of squill and digitalis, 223 
of carbonate of potash, antimony, and 
opium, 67 
senega and opium, 67 
of acetate of potash, digitalis, and 

squill, 720 
of bitart. of potash, juniper, and sp. 

setheris nitrosi, 720 
of powders of sulphurated antimony 
and Dover's powder, 81, 183 
of opium, ipecac, and nitrate of 
potash, 229 
Foods. 
Formula for gelatine-food for children, 
304 
for Merei's food for children, 305 
for preparation of raw meat, 373 
for injections in chronic hj^drocepha- 
lus, 492 
Laxatives (see also antacids). 
Formula for mixture of sulphate of soda, 
senna, and laudanum, 417 
for pill of opium and colocynth, 417 
Local applications. 
Formula for lotion of carbonate of potash 
and sulphur, 822, 861 
of lime and sulphur, 833 
of bichloride of mercury, 822 
of soft soap and alcohol (Hebra's 
sp. saponatus kalinus), 823 
for mixture of muriatic acid and 

honey of roses, 709 
for ointment of elder flowers, 829 

of glycerine and ung. aq. ros. , 709 
for benzoated oxide of zinc ointment 

(Bell's formula), 821 
for mercurial ointment to prevent 
pitting in variola, 761 



Formula for ointment of nitrate of mer- 
cury and belladonna, 60 
of protiodide of mercury, 823 
of calomel and camphor, 823 
of ammon. chl. of mercury with 

sulphur, 861 
of calomel, 887 
of tar and vin. opii, 824 
of tar and iodine, 862 
of sulphur and carbonate of pot- 
ash (Wilson), 833 
of sulphur and carb. potash (Hel- 
merich), 833 
Nervous sedatives. 
Formula for mixture of antimony, vale- 
rian, and paregoric, 68 
of antimony, valerian, and lauda- 
num, 187 
Nervous stimulants. 
Drmula for mistu 
Specific remedies. 
Formula for mixture of carbonate of pot- 
ash in hooping-cough, 244 
of alum and conium in hooping- 
cough, 245 
of alum in hooping-cough, 245 
and belladonna in hooping- 
cough, 245 
of belladonna as prophylactic in 
scarlatina, 723 
Tonics. 
Formula for mixture of codliver-oil, 325 
of nux vomica and gentian, 335 
of tr. ferri chl., acetic acid, and 

sp. mindereri, 378, 456, 801 
of quinia, morphia, and sulph. 

acid, 594 
of quinia and dil. sulph. acid, 209 
of elix. cinchona and curacoa, 209 
of arsenic and bitter wine of 
iron, 819 
Forster, temperature in new-born chil- 
dren, 37 
Fox, Wilson, on softening of stomach, 339 
Frequency of diseases (see statistics). 
Fuller, statistics of tracheotomy, 103 
Fungi in skin diseases (see parasites). 
Fungous origin of measles, 725 



Gairdner, collapse of the lung, 143-146 
lesions in bronchitis, 192, 193 
difference between dyspnoea of pneu- 
monia and bronchitis, 203 

Galls, aromatic syrup of, 369 

Gangrene, of mouth (see gangrenous sto- 
matitis), 276 
of pharynx in diphtheria, 604 

in scarlatina, 684 
of skin in erysipelas, 797 

Gargles in diphtheria, 624 

Gastritis, article on, 336-341 

frequency and nature of, 336 
causes of, 336 
anatomical lesions in, 337 
softening of stomach in, 338 



902 



INDEX. 



Gastritis, symptoms of, 339 
diagnosis of, 340 
prognosis in, 340 
treatment of, 340 
G-astromalacia (see softening of stomach). 
Gastrotoiny in intussusception, 433 
Gestures, significance of, 29 
Glands, bronchial, tuberculosis of, 643, 647 
cervical, in scarlatina, 684, 685 
intestinal, in scarlatina, 700 

in typhoid fever, 776 
mesenteric, tuberculosis of, 646, 653 
parotid, in mumps (see mumps). 

in scarlatina, 685 
submaxillary in diphtheria, 605, 607 
enlarged in some cases of mumps, 

630 
enlarged in scarlatina, 684, 685 
Glottis, spasm of, in eclampsia, 501 

(see laryngismus stridulus), 512 
Golis, on treatment of hydrocephalus, 491 
Gregory, cold affusions in scarlatina, 712 
Guersant, mortality of true croup, 96 
Guinier, statistics of paracentesis, 226 
Gum (see strophulus), 842 
Gummy tumors in congenital syphilis, 662 
Gums, importance of lancing in cholera 
infantum, 397 
in laryngismus, 522 
Gutta percha, solution of, to prevent pit- 
ting in variola, 761 
Gymnastic exercises in chorea, 567 
in infantile paralysis, 534 

Haemoptysis in pulmonary phthisis, 650 
Hair, in favus, 853 
in tinea, 859 
in alopecia areata, 864 
Hall, Marshall, on spasm of glottis in 
eclampsia, 501 
on nature of laryngismus, 517 
Hammond, electrical condition of muscles 

in infantile paralysis, 576, 577 
Harris, E. P., on hereditary nature of 

eclampsia, 496 
Head, peculiarities of in hydrocephalus, 
487 
in rickets, 636 
soft spots on, in rickets, 636 
Heart, physical examination of, 35, 36, 37 
sounds of, 36 

diseases of, article on, 260-267 
(see pericarditis and endocarditis.) 

causes of, 261 
chronic valvular diseases of, 263 
causes of, 263 

anatomical appearances in, 263 
insidious character of early symp- 
toms, 263 
physical signs in, 264 
compensation for, effected by 

growing heart, 264 
tendency to improve by time, 264 
treatment of, 264 
illustrative cases of, 266 
in chorea, 551 



Heart, irregular action of, in chorea, 555 
fattv degeneration of, in diphtheria, 

605 
inflammation of endocardium in diph- 
theria, 618 
inflammation of membranes of, in 
scarlatina, 699 
Heart-clot in diphtheria, 617, 627 
Heat, intense, as cause of enter o-colitis, 

347 
Heat of surface (see temperature). 
Hebra, on treatment of eczema, 823, 824 
Helminthocorton as a vermifuge, 884 
Hemiplegia in chorea, 555, 572 
in cerebral hemorrhage, 479 
cerebral, diagnosis of from facial pa- 
ralysis, 586 
Hemorrhage, during paroxysms of hoop- 
ing-cough, 232 
intestinal, in intussusception, &c, 430 
in typhoid fever, 783, 787 
Herpes, article on, 824-829 
definition of, 824 
varieties of, 825 
frequency of, 825 
causes of, 825 
diagnosis of, 828 
prognosis in, 828 
general treatment of, 828 
local treatment of, 829 
phlyctenodes. 

seat of eruption in, 825 
symptoms of, 825 
diagnosis of from pemphigus, 828 
treatment of, 828 
labialis. 
seat of eruption in, 826 
symptoms of, 826 
local applications in, 829 
zoster. 

definition of, 826 
seats of, 826 

character of eruption in, 827 
course and duration of, 827 
general symptoms in, 827 
pain in, 827 
diagnosis of, 828 
local applications in, 829 
circinatus (see tinea circinata), 860 
iris. 

symptoms of, 827 
seat of, 828 

parasitic nature of, 828 
diagnosis of from roseola annulata, 828 
treatment of, 829 
Hewitt, Graily, on collapse of the lung in 

hooping-cough, 236 
Hives (see urticaria), 806 
Hillier, indications for bleeding in pneu- 
monia, 180 
albuminuria in diphtheria, 617 
Holding-breath spells (see convulsions in- 
ternal), 519 
Hooping-cough, article on, 230-251 

definition, synonymes, frequency, 230 
causes, influence of age, 231 



INDEX. 



903 



Hooping-cough, contagion and epidemic 
influence, 231 
stages of, 231 

symptoms and duration of first stage, 
231 
of second stage, 231 
character of paroxysms, 232 
hemorrhages during this stage, 232 
convulsions during this stage, 233 
duration of paroxysms, 233 
number of paroxysms, 233 
symptoms and duration of third 

stage, 233 
absence of general symptoms in, 234 
urine in, 234 
total duration of, 234 
convulsions as a complication, 234 
excessive laryngismus as a complica- 
tion, 235 
collar se of the lung as a complica- 
tion, 236 
bronchitis as a complication, 237 
pneumonia as a complication, 237 
emphysema as a sequel, 237 
tuberculosis and scrofula as sequelse, 

238 
diagnosis of from acute catarrh, 238 
from tuberculosis of bronchial 
glands, 238 
prognosis in, 239 
nature of, 239 
anatomical lesions, 239 
treatment of simple form, 240 
bloodletting in, 241 
belladonna in, 242 
carbonate of potash in, 244 
alum in, 244 
inhalations in, 246 
local applications in, 246 
treatment of complications of, 247 

of paroxysms of, 250 
hygienic treatment of, 250 
Hunger, crying from, 23 
Hunt, S. B., change of residence in chronic 

diarrhoea, 362 
Hutchinson, J., alteration of teeth in con- 
genital syphilis, 661 
Hy diencephalic cr} 7 , 444 
Hydrocephalus, acute (see tubercular me- 
ningitis), 
chronic, following meningeal apo- 
plexy, 481 
article on, 484-493 
forms of, 484 

anatomical appearances in, 484 
analysis of fluid in, 485 
causes of internal form, 486 

external form, 486 
symptoms of, 487 
enlargement of head in, 487 
cerebral symptoms in, 488 
mode of death in, 489 
diagnosis of from rickets of the 
skull, 489 
from hypertrophy of the 
brain, 490 



Hydrocephalus, chronic, prognosis in, 490 
treatment of, 490 
use of mercury in, 491 
compression of head in, 492 
paracentesis in, 492 
injections into cranial cavity in, 
492 
Hydrocyanic acid in hooping-cough, 243 
Hygienic conditions, influence of unfavor- 
able, 383 
treatment in chorea, 569 
in measles, 740 
Hyposulphites, use of in scarlatina, 710 



Ice, local use of in membranous croup, 103 
in tetanus, 546 
in diphtheria, 624 
in scarlatina, 713 
in angina of scarlatina, 717 
Ichthyosis, symptoms of, 847 

treatment of, 847 
Ileus (see intussusception). 
Impetigo (see eczema impetiginoides). 
larvalis (see eczema larvale), 814 
granulata (see eczema granulatum), 

814 
figurata, 815 
sparsa, 816 
Incubation, of scarlatina, 669 
of measles, 724 
of small-pox, 747 
Indigestion, article on, 316-326 

definition, frequency, forms, 316 

causes of, 316 

symptoms of occasional form, 318 

of habitual form, 318 
diagnosis of, 320 
prognosis in, 321 

treatment of occasional form in in- 
fants, 321 
in older children, 322 
of habitual form, 323 
as cause of eclampsia, 510, 511 
Infantile remittent fever (see typhoid fe- 
ver). 
syphilis (see syphilis). 
Inflammation, catarrhal, of larynx, with- 
out spasm, 62 
with spasm, 68 
of larynx with pseudo-membranous 

exudation, 84 
of lungs, 158 
of bronchia, 188 
of pleura, 211 
Inflation, effect of on collapsed lung, and 
in atelectasis, 132, 143 
impossible in pneumonic lung, 160 
in congestion of lung, 160 
Inhalations, in treatment of membranous 
croup, 102 
of coal gas in hooping-cough, 246 
Injections (see enemata). 

into cranial cavity in hydrocephalus, 

492 
into pleural sac after paracentesis, 228 



904 



INDEX. 



Injections in nasal diphtheria, 625 
Inoculability of scarlatina, 669 
Inspection of thorax in pleurisy, 215 
Inspiration, recession of base of thorax in, 

41 
Internal convulsions (see convulsions and 

laryngismus). 
Intertrigo (see erythema), 791 
Intussusception, article on, 419-434 

definition, synonymes, and forms, 419 

frequency, 420 

anatomical appearances, 420 

divisions of, 420 
most frequent seat of, 420 
anatomy of, 421 
modes of termination of, 422 
case of elimination of the invaginated 

bowel, 423 
causes of, 423 
mode of production, 424 
symptoms of, 424 
duration of, 427 
modes of termination, 428 
prognosis in, 428 
diagnosis of, 429 
differential diagnosis of, 429 
treatment of, medical, mechanical, 

and surgical, 431-434 
use of purgatives in, 431 
injections of air and fluids in, 432 
gastrotomy in, 433 
Inunction in scarlatina, 709 

of cod-liver oil in rickets, 642 
in tuberculosis, 657 
Invasion of diphtheria often insidious, 611 
of mild cases of scarlatina, 672 
of grave cases of scarlatina, 678, 682, 

683 
of measles, 725, 730 
Iodide of potassium (see potassium). 
Iodine, in tubercular meningitis, 456 

as injection in chronic hydrocephalus, 
492 
Iron, in laryngismus stridulus, 524 
in infantile paralysis, 583 
in rheumatism, 594 
local use of in diphtheria, 623 
in tuberculosis, 657 
chloride of, with acetic acid, and sp. 
Mindereri, 378 
in diphtheria, 625, 626 
in scarlatinous angina, 718' 
in erysipelas, 801 
iodide of, in pleurisy, 222 

in chronic eczema, 820 
nitrate of, in chronic enter o-colitis, 
376 
enema of in dysentery, 403 
sulphate of, in scarlatinous angina, 
718 
Itch (see scabies), 829 



Jacobi, statistics of tracheotomv in croup 
in New York, 106, 107, 114 
local applications in diphtheria, 623 



Jenner, recession of base of chest in inspi- 
ration, 41 
on rickets, 636, 638 
Joints, condition of in rheumatism, 591, 
592 
affection of, in scarlatina, 699 



Kameela as a vermifuge, 884 
Keratitis, in congenital syphilis, 662 
Kidneys, condition of in diphtheria, 605 

in scarlatinous dropsy, 693 
Kine-pock (see vaccine diseases). 



Laborde, sclerosis of spinal cord in infan- 
tile palsy, 580 
Lancing gums (see gums). 
Laryngismus, excessive in hooping-cough, 
235 
in eclampsia, 501 
in rickets, 638 
stridulus, article on, 512-528 

definition and synonymes, 512 
frequency of, 512 
predisposing causes of, 512 
nature and exciting causes, 514 
anatomical appearances in, 514 
enlargement of thymus gland in, 

515 
centric and eccentric causes of,517 
symptoms of paroxysm of, 518 
duration and course of, 519 
danger of sudden death in, 519 
associated with spasm of other 

respiratory muscles, 519 
diagnosis of, 521 
prognosis in, 521 
treatment of, 522 
importance of lancing gums in, 
522 
attention to diet in, 522 
antispasmodics in, 524 
iron in, 524 

treatment of paroxysm, 524 
change of residence in, 525 
illustrative cases, 525 
Laryngitis, in scarlatina, 689 
in measles, 734, 745 
in small-pox, 749 
chronic. 64, 65 
pseado-7nemb7 , ano2is, 84 

definition, synonymes of, 84 
nature and relations to diphthe- 
ria, 84, 85, 86 
frequency of faucial deposit, 85, 89 
frequency of, 86 
mortality from, 86 
predisposing causes of, 87, 88 
exciting causes of, 88 
second attacks of, 88 
anatomical lesions, 88, 89, 90 
extent and characters of false 

membranes, 88, 89, 90 
mucous membrane rarely ulcer- 
ated, 90 



INDEX, 



905 



Laryngitis, pseudo-membrajwus, symp- 
toms of, 91 
of initial stage, 91 
characters of voice and cough, 
91, 92 
of respiration, 92 
explanation of recession of base 

of chest in, 93 
expectoration and rejection of 

false membrane in, 93 
negative results of auscultation 

in, 93, 112 
mode of recovery in, 95 
duration of, 96 
prognosis in, 97 
treatment of, 97 

importance of early blood- 
letting in, 97 
emetics in, 98 
mercury in, 100 
alkalies in, 101 
opium in, 101 
local treatment in, 101 
inhalations in, 102 
hygienic treatment, 102 
summary of the treatment of, 103 
tracheotomy (see under that 
head), 103 
spasmodic, simple, 68-84 
synonymes of, 69 
forms of, 69 
causes of, 69 

anatomical lesions in, 70 
symptoms of, 71 
duration of, 74 
nature of, 74 

diagnosis of from trije croup, 75 
from laryngismus stridulus, 
521 
peculiarities of voice in, 77 

respiration in, 77 
prognosis in, 78 
treatment of the mild form, 79 

of the severe form, 81 
hygienic treatment of, 82 
prophylactic treatment of, 83 
style of dress suitable in, 83 
simple, without spasm, 62 

definition and frequency of, 62 
causes of, 62 

anatomical lesions in, 63 
symptoms and course of, 63 
duration of, 65 
diagnosis of, 65 
prognosis in, 66 
treatment of, 66 
Larynx, general remarks on diseases of, 61 
Legendre and Bailly, nature of atelecta- 
sis, 139 
researches on collapse of lung, 140, 154 
Lichen, article on, 843, 844 

tropicus, the variety usually met with, 
843 
frequency of, 843 
cause of, 843 
symptoms of, 844 



Lichen, tropims, duration of, 844 

diagnosis of, 844 

of from scabies, 832 

prognosis in, 844 

treatment of, 844 
urticatus {see urticaria), 807 
Liebig, food for infants, 305 
Liver, state of in entero-colitis, 354 
in rickets, 640 
in congenital syphilis, 662 
Lobular pneumonia, in reality collapse of 

lung, 140 
Local applications in chronic coryza, 59,60 

in membranous croup, 101 

in pneumonia, 184 

in bronchitis, 207 

in pleurisy, 223 

in hooping-cough, 247 

in aphtha?, 271 

in ulcero-membranous stomatiti's, 275 

in gangrene of the mouth, 283 

in thrush, 309 

of cold in tubercular meningitis, 458 

in eclampsia, 507 

in rheumatism, 595 

in diphtheria, 621 

in mumps, 631 

in congenital syphilis, 664 

to throat in scarlatina, 708, 709, 717 

external in scarlatina, 707, 709, 711 

in erysipelas, 800 

in eczema, 820 

in herpes, 829 

in scabies, 832 

in pemphigus, 836 

in rupia, 838 

in ecthyma, 841 

in strophulus, 843 

in lichen, 844 

prurigo, 846 

in psoriasis, 847 

in pityriasis, 847 

in ichthyosis, 847 

in favus, 856 

in tinea, 861 

in alopecia areata, 865 
Lotions (see formulas). 

of water in scarlatina, 711, 714 

in treatment of eczema, 822 
Lumbricus (see ascaris lumbricoides). 
Lungs, auscultation of, 42, 43, 44 

general remarks on diseases of, 130 

collapse and imperfect expansion of, 
131, 153 

inflammation of, 153 

abscess of, following pneumonia, 159 

congestion of, non-inflammatory, 159 

condition of in pleurisy, carnification, 
213 

collapse of, in rickets, 640 

tuberculosis of, 644, 649 

percussion of, 43, 45, 46 

condition of, in congenital syphilis, 
662 
in typhoid fever, 778, 782 
in sclerema, 869 



906 



INDEX. 



Magnesia, hyposulphite of in scarlatina, I 

710 
Marsh, F. H., on tracheotomy in croup, 

115 
Maturative fever in variola, 750, 758 
Maw-worm (see ascaris vermicularis). 
Measles (see rubeola), 723 
French (see roseola). 
Meigs, Charles D , treatment of coryza, 58 
use of alum as an emetic, 99 
on proper position of body in atelec- 
tasis and cyanosis, 138, 260 
treatment of paroxysm of laryngis- 
mus, 524 
Meigs, J. F., case of contraction with ri- 
gidity, 532 
heart-clot in diphtheria, 618 
Membrane, false (see false membrane). 
Meningeal apoplexy (see cerebral hemor- 
rhage), 475 
Meningitis, simulated by cerebral form of 
pneumonia, 176 
sim])le, article on, 464-471 

definition, synonymes, frequency, 

464 
causes of, 464 
anatomical lesions in, 465 
symptoms of convulsive form, 466 

of phrenitic form, 467 
course and duration of, 468 
diagnosis of from congestion of 
brain, 469 
from tubercular form, 449 
prognosis of, 469 
treatment of, 469 
bleeding in, 470 
calomel in, 470 

cold and counter-irritation in, 470 
tubercular, article on, 436-464 

definition, synonymes, and fre- 
quency, 436, 437 
predisposing causes of, 437 
anatomical lesions in, 438 
microscopical changes in, 438 
division into stages, 441 
mode of invasion, 442 
symptoms of first stage, 443 
hydrencepbalic cry. 444 
condition of mind in, 444 
use. of ophthalmoscope in, 445 
convulsions in, 446 
circulation in, 446 
symptoms of second stage, 447 
tache meningitique, 447 
nervous symptoms in, 448 
decubitus in, 448 
pulse in, 448 
temperature in, 449 
diagnosis of, from simple menin- 
gitis, 449 
from typhoid fever, 450 
prognosis in, 451 
case of apparent recovery from, 

452 
prognosis not absolutely hope- 
less, 454 



Meningitis, tubercular, uncertainty of 
date of death in, 455 
treatment of, 455 
bleeding not to be used, 455 
iodine and iodide of potassium 

in, 456 
counter-irritation in, 458 
cold applications in, 458 
calomel and mercury in, 459 
prophylaxis in, 461 
diet in, 461 
importance of country residence, 

462 
illustrative case, 462 
in typhoid fever, 777 
Mental condition in rickets, 635 
Mercurial ointment to prevent pitting in 
variola, 760 
applications in eczema, 824 
in favus, 857 
in tinea, 861 
Mercury (see calomel). 

in membranous croup, 100 

in pneumonia, 183 

in pleurisy, 222 

in diseases of coecum and appendix, 

418 
in tubercular meningitis, 460 
in congenital syphilis, 663 
Metastasis in mumps, 631 
Microscopic examination of milk, 307 
of false membranes in diphtheria, 603 
changes in tubercular meningitis, 438 
in spinal cord in tetanus, 541 
in chorea, 553 
ininfantileparalysis,580 
in muscle in infantile paralysis, 
577 
in progressive paralysis, 590 
in kidneys in scarlatinous dropsy, 
693 
Microsporon furfur, 850 
Miliary tubercles, 438, 439 
Milk (see also food and diet). 

properties of and mode of examining 

cow's milk, 298 
mode of preserving, 300 
proper dilution of, for infants, 301 
quantity of, for infants, 301 
preparation of, 303 
human, analysis of, 306 

microscopic examination of, 307 
mode of examining and proper- 
ties of, 307 
substitutes for, 297-306 
Milk-crust (see eczema capitis), 812 
Morbilli (see rubeola), 723 
Mortality (see statistics). 
Mouth, examination of, 47 
mode of examining, 48 
diseases of (see stomatitis), 268 
Mucous membrane, condition in entero- 
colitis, 351 
of fauces in diphtheria, 603, 604 
of larynx in diphtheritic croup, 604 
affections of in congenital syphilis, 660 



INDEX. 



907 



Mucous membrane of fauces, in scarla- 
tina. 684 
gastro-intestinal in scarlatina, 700 
eruption on, in small-pox, 749 
condition of, in small-pox, 755 

in cases of ascaris lurnbricoides, 
875 
Iffnguet (see thrush). 
Mumps, article on, 628-632 

definition, synonyrnes, and frequency 

of, 628 
causes of, 628 

anatomical appearances in, 629 
symptoms of, 629 
characters of swelling in, 629 
salivary secretion in, 680 
general symptoms in, 630 
tendency to metastasis in, 631 
prognosis always favorable in, 631 
course and duration of, 631 
usually terminates by resolution, 631 
suppuration of parotid in, 631 
diagnosis of, 631 
treatment of, 631 
danger of febrile sequelsein, 632 
Muriate of ammonia (see ammonia). 
Muriatic acid (see acid). 
Murmur, cardiac in chorea, 551, 556 

cerebral in rickets, 635 
Muscle, condition of in atrophic infantile 
paralysis, 577 
in progressive paralysis, 590 
Muscular paralysis, progressive (see pa- 
ralysis), 587 



Nasal variety of diphtheria, 610 
Nature of spasmodic laryngitis, 74 

of pseudo-membranous laryngitis and 
diphtheria, 84 

of collapse of the lung, 139 

of pneumonia, 154 

of hooping-cough, 239 

of cyanosis, 256 

of aphthae, 270 

of thrush, 288, 291 

of simple diarrhoea, 326 

of gastritis, 336 

of entero-colitis, 354 

of cholera infantum, 384 

of diseases of ccecum and appendix, 
405, 406 

of cerebral congestion, 471 

of chronic hydrocephalus, 486 

of eclampsia, 500 

of laryngismus stridulus, 514 

of contraction with rigidity, 529 

of chorea, 557 

of atrophic infantile paralysis, 577 

of progressive paralysis, with appar- 
ent hypertrophy of the muscles, 590 

of diphtheria. 600 

of mumps, 628 

of rickets, 641 

of scarlatina, 668 

of rubeola, 723 



Nature of variola, 747 
of varicella, 773 
of typhoid fever, 776 
of erysipelas, 796 
of herpes iris, 828 
of scabies, 829 
of prurigo, 845 
of parasitic skin diseases, 848 
of favus, 854 
of alopecia areata, 864 
Nephritis, after scarlatina, 691-698 
Nervous system, general remarks on dis- 
eases of, 435 
symptoms (see cerebral symptoms). 
Nettle-rash (see urticaria). 
Neurosis, evidence in favor of hooping- 
cough being a, 240 
of laryngismus stridulus be- 
ing a, 516 
infantile paral} T sis not a, 577 
Niemeyer, indications for bleeding in 
pneumonia, 182 
on lesions in catarrh of stomach, 338 



Obstruction of the intestines (see intussus- 
ception), 419 
Occipital bone, depression of as cause of 

tetanus, 539 
(Edema of face in bronchial phthisis, 648 

of neck in scarlatina, 685 

in variola, 750 

in typhoid fever, 784 

in erysipelas, 798 

in sclerema, 867 
Ogle, J. W., on chorea, 548 
Oidium albicans (see thrush), 291 
Ointments (see local applications). 

in treatment of seat-worms, 887 
Omentum, tuberculosis of, 645 
Ophthalmia, in variola, 759 
Ophthalmoscope in tubercular meningi- 
tis, 445 
Opium in catarrhal croup, 81 

in membranous croup, 101 

in pneumonia, doses and mode of ad- 
ministering, 186 

in pleurisy, 222 

in thrush^ 309 

in entero-colitis, 366 

in cholera infantum, 393 

in dysentery, 402 

in diseases of coecum and appendix, 
417, 418 

in eclampsia, 509 

in rheumatism, 595 

in variola, 758 

in typhoid fever, 787 
Otorrhcea, in scarlatina, 658, 698, 719 
Ova of acarus scabiei, 831 



Packing, cold, in scarlatina, 713 
Pain, modes of expressing, 22 

in pneumonia, seats and peculiarities 
of, 163, 172 



908 



INDEX. 



Pain in pleurisy, seats and peculiarities of, 
215 
abdominal, in intussusception, 426 
in tuberculous peritonitis, 653 
in variola, 747 
Palpation, of thorax in pleurisy, 215 
Pancoast, J., on tracheotomy in croup, 

108, 117 
Papules, chapter on, 842 

in small-pox, 748 
Paracentesis, in pleurisy (see pleurisy), 
223-228 
in hydrocephalus, 492 
Paralysis, in tubercular meningitis, 448 
in cerebral hemorrhage, 480, 483 
in chorea, 555, 572 
in diphtheria, 619 
after scarlatina, 699 
atrophic infantile, article on, 569-586 
history of and authors on, 569 
synonymes of, 571 
causes of, 571 
forms of and muscles affected in, 

572 
mode of attack, 572 
reaches its maximum suddenly, 

572 
condition of paralyzed muscles 

in, 573 
illustrative case of, 573 
at times temporary, 574 
at other times followed by atro- 
phy, 574 
temperature lowered in palsied 

parts, 574 
subsequent deformities in, 575 
duration of, 575 
prognosis in, 576 
electrical condition of muscles as 

aid in prognosis, 576, 584 
microscopic examination of mus- 
cles in, 577 
anatomical lesions in and nature 

of, 577 
cannot be considered reflex, 578 
primary condition usually one of 

spinal congestion, 578 
sclerosis of cord in a later stage, 579 
other lesions of cord occasionally 

met with, 579 
diagnosis of from other forms of 
paralysis, ";81 
from progressive muscular 
atrophy, 581 
occasionally simulates coxalgia, 

582 
use of local treatment to spine in, 

582 
ergot, belladonna, and iodide of 

potassium in acute stage, 582 
iron and strvchnia in later stage, 

583 
use of electricity in, directions 

for choice of current, 583 
mechanical contrivances in treat- 
ment of, 584 



Paralysis, atrophic infantile, tenotomy to 
relieve deformity, 585 
necessity of pursuing treatment 
for years, 585 
facial, article on, 586, 587 
causes of, 586 
symptoms of, 586 
diagnosis of from cerebral hemi- 
plegia, 586 
prognosis in, 586 
treatment of, 587 
•progressive, with apparent hypertro- 
phv of the muscles, article on, 
587-590 
definition of, 587 
history and synonymes of, 587 
causes of, 588 
symptoms of, 588 
peculiar gait in, 588 
condition of muscles in, 589 
marked loss of voluntary power 

in, 589 
mental condition in, 589 
duration variable, 589 
termination fatal, by affection of 

respiratory muscles, 589 
diagnosis of, 590 
anatomical appearances in, 590 
treatment of, 590 
Parasite of thrush (see oidium albicans), 
of favus (see achorion Schoenleinii), 

849 
of tinea tricophytina (see tricophy- 

ton), 850 
of tinea versicolor (see microsporon), 

850 
of alopecia areata, 850 
Parasitic skin diseases, 848-865 
general remarks on, 848 
varieties of, 848 
nature of, 848 

mode of detecting fungus in, 848 
relation between fungus and the erup- 
tion, 849 
description of achorion Schoenleinii 

(see favus aleo), 849 
description of tricophvton (see tinea 

also), 850 
description of microsporon furfur (see 

alopecia areata), 850 
relation of the various fungi in, 850 
diagnosis of, 851 
Parasiticides, 856-858 
Parotid gland, condition of in mumps, 629 

suppuration of in mumps, 631 
Parotitis (see mumps). 

in typhoid fever, 783 
Paroxysm of hooping-cough, peculiarities 
of, 232 
treatment of, 250 
of laryngismus stridulus, symptoms 
of, 518 
treatment of, 524 
of eclampsia, symptoms of, 498 

treatment of, 509 
in tetanus, 543 



INDEX. 



909 



Paroxysm in diphtheritic croup, 609 
Parrot, on thrash, 290, 292 
Pelvis, alterations of in rickets, 687 
Pemphigus infantilis (see rupia escharot- 

iea). 
Pemphigus, in congenital syphilis, 659, 
834 ' 
article on, 834-836 
definition and synonymes of, 834 
forms and frequency of, 834 
causes of, 834 
symptoms of. 834 
duration of, 835 
diagnosis of, 835 
prognosis in, 885 
general treatment of, 835 
local treatment of, 836 
Pepper, Prof., case of laryngismus stridu- 
lus, 52S 
incontinence of urine in chorea, 555 
Pericarditis, acute, symptoms and diffi- 
culty of detection of, 261, 262 
prognosis in, 262 
anatomical appearances in, 262 
treatment of, 262 
chronic, 262 
Percussion of heart, 36 

of lungs, mode of performing, &c, 

43, 45, 46 
in pneumonia, 164, 170 
in pleurisy, 214, 215 
in bronchial phthisis, 648, 649 
in pulmonary phthisis, 649, 650 
Perforation of intestine in typhoid fever, 
783, 787 
from ascaris lumbricoides, 875 
Peritoneum, tuberculosis of (see tubercu- 
losis), 645, 652 
Peritonitis, from perforation of ccecum 
and appendix, 410, 414 
tuberculous (see tuberculosis), 645, 652 
in scarlatina, 699 
Perityphlitis, in art. on dis. of coecum 
and appendix, 404-419 
definition, 405 
iliac, abscess in, 406 
anatomical appearances in, 409 
symptoms of, 414 
Perspiration, tendency to profuse, in rick- 
ets, 635 
Pertussis (see hooping-cough), 230 
Pharyngitis, simple, 310-315 

definition, synonymes, and fre- 
quency, 310 
causes of, 310 
lesions in, 310 
symptoms of, 311 
diagnosis of, 813 
prognosis of, 314 
treatment of, 314 
Phlyzacia (see ecthyma), 839 
Phthisis (see tuberculosis). 
Physical signs (see auscultation and per- 
cussion). 
Physiognomy in diseases, 21 
in pneumonia, 163, 173 



Physiognomy in pleurisy, 217 

in diseases of heart, "261, 262, 264 
in tetanus, 642 
in cases of worms, 877 
Pinkroot as a vermifuge, 881 
Pitting in variola (see under variola), 751 
in varioloid, 754 
treatment to prevent, 759 
Pityriasis, symptoms of, 847 

treatment of, 847 
Pleurisy, article on, 211-280 

definition, frequency, and forms, 211 
predisposing causes of, 211 
exciting causes of, 212 
anatomical lesions in, 212 
symptoms of apute form, 213 
physical signs from auscultation, 213 
percussion, 214 
inspection, 215 
palpation, 215 
rational symptoms, pain, cough, res- 
piration, pulse, 215 
urine in, 217 
symptoms of chronic form, 217 

of empyema, 218 
diagnosis of, 219 
obscurity in early stage from violence 

of constitutional symptoms, 220 
prognosis and mortality in, 220 
treatment of, 221-228 
bloodletting in, 221 
antimony in, 221 
mercury in, 222 
diuretics and purgatives in, 223 
external remedies in, 223 
paracentesis, 223-228 
indications for, 224 
objections to, 224 
Trousseau's rule in regard to, 225 
indicated in empyema, 225 
success greater in children, 226 
mode of performing, 226 
after treatment, 227 
use of medicated injections 
through canula, 228 
illustrative case of chronic form, 228 
Pleuro-pneumonia, physical signs in, 214 

mortality in, 220 
Pneumonia, lobular, in reality collapse of 
the lung, 140 
differences between condition of lung 

in, and in collapse, 142, 143 
in hooping-cough, 237 
in measles, 732-734 
article on, 153-188 
definition and synonymes of, 158 
frequency and mortality of, 153 
forms and classification, 154 
lobular, identity of with collapse, 154 
predisposing causes, 155 
table showing influence of season, 157 
relation of mortality from, to the tem- 
perature, 157 
exciting causes of, 157 
anatomical lesions of, 157 
of lobular form, 158 



910 



INDEX. 



Pneumonia, anatomical lesions, of partial 
form, 159 
abscesses of lung following, 159 
difference between condition of lung 
in, and in non-inflammatory con- 
gestion, 160 
inflation of lung impossible in, 160 
usually unilateral, 160 
portion of lung involved in, 160 
apex quite frequently the seat of, 161 
not so frequently attended by bron- 
chitis as formerly thought, 161 
association with pleurisy, 162 

with emphysema, 162 
general course of, in young children, 
162 
in children overtwoyearsold, 166 
varieties of mode of onset, simulating 

other affections, 166 
unfavorable symptoms and modes of 

death, 168 
general course of the partial form, 169 
duration of, 170 
physical signs of, 170 
cough in, 171 
expectoration in, 171 
thoracic pain in, 163, 172 
state of respiration in, 163, 172 
physiognomy in, 173 
grade of fever in, 164, 167, 173 
rate of pulse in, 164, 167, 173 
nervous symptoms, convulsions, 173 
appetite, vomiting, diarrhoea in, 174 
urine; albuminuria in, 174 
diagnosis from bronchitis, 175 
from pleurisy, 175 
of partial form, 175 
of cerebral form, 176 
during teething, 177 
from typhoid fever, 785 
prognosis of, 177 
treatment of, 179-188 
question of bloodletting in treatment 

of, 179 
indications for bleeding in, 181 
use of antimony in, 182 
calomel in, 183 
salines in, 183 
ipecacuanha in, 184 
purgatives in, 184 
external applications in, 184 
indications for tonics and stimulants 

in, 185 
diet in, 185 

stimulus and tonics in, 186 
use of opium in, 186 
general management of, 187 
importance of administration of wa- 
ter in, 188 
confinement to bed, 188 
change of position in, 188 
relations of to tuberculosis of the 

lungs, 643, 652 
in typhoid fever, 783 
Pneumothorax, from rupture of abscess of 
the lung, 159 



Pock, anatomy of variolous, 755, 756 

of vaccine, 763 
Pompholyx (see pemphigus), 834 
Porrigo (see tinea), 858 
Porrigo larvalis (see eczema capitis), 812, 
814 
granulata (see eczema granulatum), 

814 
favosa (see favus), 852 
scutulata (see favus), 852 
Position recommended in atelectasis, 138 
Potash, carbonate of, in hooping-cough, 
244 
and acetateof, in rheumatism, 594 
ointment of, in eczema, 823 
chlorate of, in ulcerative stomatitis, 
275 
in diphtheria, 626 
in scarlatina, 710 
caustic solutions of, in eczema, 823 
Potassium, bromide of, in eclampsia, 510 
iodide of, in pleurisy, 222 

in chronic valvular disease of the 

heart, 264 
in tubercular meningitis, 456 
in chronic hydrocephalus, 491 
in infantile paralysis, 582 
in rheumatism, 594 
sulphuret of, baths of, in chorea, 566 
Poultices in pneumonia, 185 
in bronchitis, 207 
in eczema, 821, 822 
in favus, 857 
in coryza, 55, 56 
in simple laryngitis, 66 
Prognosis in spasmodic simple laryngitis, 
78 
in pseudo-membranous laryngitis, 96 
in atelectasis pulmonum, 137 
in collapse of the lung, 150 
in pneumonia, 177 
in bronchitis, 203 
in pleurisy, 220 
in hooping-cough, 239 
in acute pericarditis, 262 
in chronic valvular diseases, 264 
in chronic valvular disease of the 

heart, 264 
in aphthae, 271 
in ulcerative stomatitis, 274 
in gangrene of the mouth, 282 
in thrush, 296 
in simple pharyngitis, 314 
in indigestion, 321 
in simple diarrhoea, 331 
in gastritis, 340 
in entero-colitis, 360 
in cholera infantum, 390 
in dysentery, 401 
in diseases of coecum and appendix, 

415 
in intussusception, 428 
in tubercular meningitis, 451 
in simple meningitis, 469 
in cerebral congestion, 474 
in cerebral hemorrhage, 482 



INDEX. 



911 



Prognosis in chronic hydrocephalus, 490 

"in eclampsia, 504 

in laryngismus stridulus, 519, 521 

in contraction with rigidity, 582 

in tetanus, 543 

in chorea, 560-562 

in atrophic infantile paralysis, 576 

in facial paralysis, 586 

in progressive paralysis, 589 

in acute rheumatism, 593 

in diphtheria, 614 

in diphtheritic paralysis, 620 

in mumps, 631 

in rickets, 638 

in tuberculosis, 656 

in congenital syphilis, 663 

in scarlatinous dropsy, 698 

in scarlatina, 702 

in rubeola, 739, 740 

in variola, 756 

in varioloid. 756 

in varicella, 774 

in typhoid fever, 784 

in erythema, 793 

in erysipelas, 798 

in roseola, 805 

in urticaria, 808 

in eczematous affections, 817 

in herpes, 828 

in scabies. 832 
'in pemphigus, 835 

in rupia, 838 

in ecthyma, 840 

in strophulus, 843 

in lichen, 844 

in prurigo, 845 

in favus, 855 

in tinea, 860 

in alopecia areata, 865 

in sclerema, 867 

in ascaris lumbricoides, 880 

in ascaris vermicularis, 886 
Prurigo, article on, 844-846 

definition of, 844 

frequency of, 845 

causes of, 845 

symptoms of, 845 

duration of, 845 

diagnosis of, from strophulus or lichen , 
845 
from scabies, 832 

prognosis in, 845 

treatment of, 845 
Pseudo-membranous angina (see diphthe- 
ria), 596 
in true croup, 85 

laryngitis (see laryngitis). 
Psoriasis, diffusa, symptoms of, 846 

guttata, symptoms of, 846 
treatment of, 847 
Pulmonary resonance, characters in chil- 
dren, 45 

tuberculosis, 644, 649 
Pulse, in children, 33, 34, 35 

rate of, at different ages, 33, 34 

intermittence or irregularity of, 35 



Pulse, irritability of, 35 

to be examined during sleep, 35 

peculiarities of, in tubercular menin- 
gitis, 446, 448 

in mild cases of scarlatina, 674 

in grave cases of scarlatina, 680 

in variola, 750, 753 

in typhoid fever, 782 
Purgatives (see formulas) in pleurisy, 223 

in diseases of ccecum, 417 

in intussusception, 431 

in eclampsia, 508 

in chorea, 562 

in rheumatism, 595 

in scarlatina, 708, 710 

in scarlatinous dropsy, 720 

in rubeola, 740 

in variola, 757 

in eczema, 818 

in worms, 882 
Pustules in variola, 749 

chapter on, 839 



Quinia in pneumonia, 186 
in bronchitis, 208 
in entero-colitis, 371 
in tetanus, 546 
in rheumatism, 594 
in diphtheria, 625 
in variola, 758 
in typhoid fever, 787 



Rachitis (see rickets). 

Radcliffe, J. N., electrical condition of 

muscles in infantile paralysis, 676 
Rashes, 790 

Raw meat, use of, in entero-colitis, 373 
Reaction of cow's and human milk, 298, 

306 
Recession of base of chest in inspiration, 

41 
Rees, G. A., recession of base of chest in 
inspiration, 41 
respiration in collapse of the lung, 
134 
Reflex irritability exaggerated in early 

stage of pleurisy, 220 
Relapses of chorea, 556, 557 
of acute rheumatism, 592 
of typhoid fever, 779, 784 
Remittent Fever (see typhoid fever). 
Residence, change of, in laryngismus strid- 
ulus, 525 
in unhealthy localities, influence of, 

361 
change of, in treatment of entero-co- 
litis, 361 
in country, importance of, 462 
Resonance, pulmonary, character in chil- 
dren, 45 
Respirations, general characters of, in 
children, 39, 40, 41, 44 
rate of, 39 
expiratory, 40 



912 



INDEX. 



Kespirations, diagnostic signs from, 41 
peculiar in atelectasis and croup, re- 
cession of base of thorax, 41, 93, 134 
puerile, 44 

alteration of, in simple laryngitis, 63 
in catarrhal croup, 77 
in true croup, 93 
in pneumonia, 163, 164, 172 
in bronchitis, 201, 203 
in pleurisy, 216 
in bronchial phthisis, 648 
in typhoid fever, 778, 772 
in sclerema, 867 
Eespiratory muscles affected in some cases 
of chorea, 555 
organs, diseases of, 52 

condition of, in measles, 738 
Rest, importance of, in cholera infantum, 
396 
in bed, importance of, in rheumatism, 
595 
Return-cry, alteration of, 26 
Re vaccination, 771 
Rhagades in congenital syphilis, 661 
Rheumatism as a cause of heart 
261 
of chorea, 548 
in scarlatina, 699, 719 
acute, article on, 591-596 
symptoms of, 591 
temperature in, 591 
condition of joints in, 591 
local symptoms often compara- 
tively slight, 592 
duration and tendency to re- 
lapses, 592 
causes of, 592 

influence of sex not yet deter- 
mined, 592 
chorea as complication of, 548 
heart disease as complication of, 

261 
prognosis in, 593 
diagnosis difficult when local 

symptoms are slight, 593 
treatment of, 593 
alkalies in, 594 
iron and quinia in, 594 
opium in, 595 
local applications in, 595 
importance of strict rest in bed, 

595 
diet in, 595 

treatment of complications, 596 
Richardson, B. W., heart-clot in diph- 
theria, 617, 618 
Rickets as cause of laryngismus stridulus, 
513, 638 
article on, 632-642 
frequencv of, in England and Ameri- 
ca, 632" 
bibliography of, 633 
causes of, 634 

symptoms of initiatory stage, 635 
digestive disturbances in, 635 
general soreness of body in, 635 



Rickets, tendency to profuse perspiration 
in, 635 
dentition impeded in, 635 
urine in, 635 
mental condition in, 635 
cerebral blowing murmur in, 635 
stage of deformity, 636 
alterations of long bones in, 636 
of head in, 636 
of spine in, 637 
of thorax in, 637 
of thorax due to atmospheric pres- 
sure, 637 
of pelvis in, 637 
general S3 T mptoms in later stage, 638 

in favorable cases, 638 
secondary diseases causing death in, 

638 
prognosis and duration in, 638 
diagnosis of, 639 
morbid anatomy of bones in, 639 
collapse of lung in, 640 
condition of viscera in, 640 
pathology of, 641 
treatment of, 641 
importance of proper diet in, 641 

cod-liver oil in, 642 
means of avoiding deformities, 642 
Rilliet and Barthez, size of heart b}^ per- 
cussion, 36 
diagnosis between true and false 

croup, 76 
atelectasis and collapse of the 

lung, 142 
congestion of lungs, 194 
state of vessels in gangrene of the 

mouth, 278 
diagnosis of gangrene of the 
mouth from ulcero-membran- 
ous stomatitis, 282 
lesions in diarrhoea, 328 
on pathology of cholera infantum, 

384 
diagnosis of simple from tuber- 
cular meningitis, 449 
diagnosis of simple meningitis 
from congestion of the brain, 
469 
diagnosis of symptomatic from 

essential contraction, 531 
on convulsions in scarlatina, 704 
cold affusion in scarlatina, 713 
Roger, pulse in children, 34 
respiration in children, 39 
and Barth, auscultation in croup, 94 
Rokitansky, on changes in spinal cord in 

tetanus, 541 
Rosalia or rubeola notha, 702 
Roseola, epidemic, or rubeola notha, 702 
article on, 803-806 
definition and synonymes, 803 
frequency of, 803 
forms of, 803 

causes ; occasionally epidemic, 803 
symptoms of; eruption, 803 
duration of, 804 



INDEX. 



913 



Roseola annulafa. 

symptoms of, 804 
diagnosis of, from scarlatina, 804 
from rubeola, 805 
from herpes iris, 828 
prognosis in. 805 
treatment of, 806 
Round- worm (see ascaris lumbricoides), 

870 
Rubeola notha, 702 

sine catarrho, a form of roseola, 731, 

803 
article on, 723-745 
definition of, 723 
forms of, 723 
frequency of, 665, 723 
epidemic nature of, 723 
contagiousness of, 724 
period of incubation of, 724 
influence of age on frequency of, 724 
straw-fungus as cause of, 725 
mode of invasion of regular form of, 

725 
fever in initial stage of, 725 
catarrhal symptoms in initial stage, 

726 
marked drowsiness in initial stage of, 

726 
convulsions in initial stage of, 727 
red papules on palate in initial stage 

of, 727 
duration of initial stage of, 727 
date of appearance of eruption in, 728 
characters of eruption in, 728 
symptoms during eruption in, 728 
duration of eruption in, 729 
urine during eruption in, 729 
symptoms of stage of decline of, 729 
desquamation in, 729 
temperature in, 729 
irregularities of prodromic stage, 730 

of eruption, 730 
petechial character of eruption with- 
out any malignant symptoms, 731 
form of, without eruption, 731 
sine catarrho, a form of roseola, 731 
malignant form of, 732 

eruption in, 732 
complications and sequelae of, 732-737 
bronchitis and pneumonia in. 732-734 
effect, of upon eruption, 733 
prognosis in, 734 
laryngitis in, 734 
enteritis in, 734 

frequency of, 735 
causes of, 735 
symptoms of, 735 
fatal cerebral symptoms in, 735 
serous effusions in, 736 
tendency of, to develop tuberculosis, 

737 
coexisting with variola, scarlatina, or 

erysipelas, 737 
anatomical lesions in, 737 
diagnosis of, 738, 739 



Rubeola notha, diagnosis of from variola, 
738 
from tj'phus, 738 
prognosis in, 739, 740 
causes of death in, 739, 740 
hygienic treatment of, 740 
laxatives and febrifuges in, 741, 742 
depletion in, 742 

treatment of malignant form of, 742 
of pulmonary complications in, 
743 
counter-irritation in pulmonary com- 
plications in, 743 
treatment of diarrhoea in, 744 
of laryngitis in, 744 
of cerebral symptoms in, 744 
Rupia, article on, 836-839 
definition of, 836 
varieties of, 836 
causes of, 836 
symptoms of, 836 
diagnosis of. from pemphigus, 838 

from ecthyma, 838 
prognosis in, 838 
general treatment of, 838 
local treatment of, 838 
simplex. 

symptoms of, 836 
prominens. 

symptoms of, 837 
eseharotica. 

symptoms of, 837 



Salines, 



of membranous 
183 



830 



830 



from roseola, 805 



m treatment 

croup, 101 
of pneumonia, 
Salisbury, on straw fungus as cause of mea 

sles, 725 
Salivary secretion in mumps, 630 
Santonin as a vermifuge, 883 
Scabies, article on, 829-833 
definition of, 829 
caused by acarus scabiei 
seat of eruption in, 830 
local symptoms in, 830 
character of eruption in 
cuniculi in, 830 
mode of detecting acarus, 831 
general symptoms of, 831 
description of the acarus, 831 
diagnosis of, by finding acarus or its 
ova, 831 
from eczema simplex, 817, 832 
from prurigo, 832 
from lichen, 832 
prognosis in, 832 
treatment of, 832 

applications of sulphur in [see formu- 
las), 832 
substitutes for sulphur in, 833 
tarry applications in, 833 
carbolic acid in, 833 
general treatment of, 833 
Scarlatina, article on, 665-723 
definition of, 665 



58 



914 



INDEX. 



Scarlatina, frequency of, 665 
forms of, 666 

contagion as a cause of, 668 
period of incubation of, 669 
transmitted by fomites, 669 
inoculability of, 669 
epidemic nature of, 669 
occasional occurrence of second at- 
tacks of, 670 
influence of age upon frequency of, 670 

of sex upon, 671 
symptoms of mild cases of, 672-677 
invasion generally sudden in, 672 
occasionally a short prodromic stage, 

673 
characters of eruption in, 673 
duration of eruption in, 674 
pulse and fever in stage of eruption, 674 
tongue in stage of eruption, 674 
urine in stage of eruption, 675 
fauces in stage of eruption, 676 
symptoms of decline of, 675 
desquamation in, 676 
duration of mild cases, 676 
temperature in, 676 
no sharp line between mild and grave 

cases, 677 
symptoms of grave cases of, 677-691 
sudden invasion in ataxic form of, 678 
general symptoms in ataxic form of, 

680 
convulsions in ataxic form of, 680 
delusive improvement in ataxic form 

of, 680 
eruption in ataxic form of, 681 
fatal symptoms in ataxic form of, 682 
invasion of grave cases sometimes less 

sudden, 682 
condition of fauces in grave cases, 683 
swelling of submaxillary and cervical 

glands in grave cases, 684 
coryza and otorrhcea in grave cases, 

685, 698 
eruption in grave cases, 686 
general symptoms in grave cases, 686 
cases of this grave form, 687 
laryngitis in grave form, 689 
duration of grave form, 691 
complications and sequelae of, 691-699 
dropsy as a sequel of, 691-698 

preceded by albuminuria, 691 
frequency of, verjr variable, 692 
period of occurrence, 692 
usually due to cold, 692 
due to tubal nephritis, 693 
condition of kidneys in, 693 
preceded by febrile svmptoms, 694 
seat of effusion in, 695, 697 
course and duration of, 695 
modes of death in, 695 
uraemic symptoms in, 695 
urine greatly diminished in, 696, 
698 
characters of in, 697 
prognosis in, 698 
uraemia not necessarily fatal, 698 



Scarlatina, diarrhoea as a complication of, 
698 
rheumatism during, 699 
inflammation of serous membranes in, 

699 
endo- or pericarditis in, 699 
peritonitis in, 699 
complicated with variola, measles, or 

diphtheria, 699 
paralysis after, 699 
anatomical lesions in, 699 
condition of gastro-intestinal mucous 
membrane in, 700 
of skin in, 700 
of blood in, 700 
diagnosis of from measles, 700 
from roseola, 701, 805 
from diphtheria, 615, 701 
from rubeola notha, 702 
from erythema fugax, 790 
prognosis in, very variable in differ- 
ent epidemics, 702 
in mild cases, 703 
in grave cases, 703 
grave significance of convulsions in, 

704 
unfavorable symptoms in, 705 
favorable symptoms in, 706 
hygienic treatment of, 706 
diet in, 707 

treatment of mild cases, 707-710 
use of warm baths and affusion in mild 

cases, 707 
care in use of purgatives in mild 

cases, 708 
treatment of angina in mild cases, 708 
inunction in, 709 

treatment of grave cases, 710-719 
care in use of purgatives in grave 

cases, 710 
use of hyposulphites in grave cases, 
710 
chlorate of potash in grave cases, 

710 
lotions in grave cases, 711, 714 
cold affusions in grave cases, 711 
general remarks on baths, lotions, and 

affusions in grave cases, 715 
use of tonics and stimulants in grave 

cases, 716 
treatment of angina in grave cases, 71 7 
external use of ice in grave cases, 717 
mode of making applications in grave 

cases, 719 
treatment of the rheumatism in, 719 
of otorrhoea, 719 
of mild cases of dropsy, 719 
of severe cases of dropsy, 719 
counter-irritation in dropsy, 720 
diuretics in, 720 

hot baths as diaphoretics in dropsy, 720 

treatment of cerebral symptoms in 

dropsy, 721 

of the later stages of dropsy, 721 

use of belladonna as a prophylactic 

in, 721 



INDEX. 



915 



Sclerema, article on, 865-869 

definition and synonymes of, 865 
frequency of. 865 
date of occurrence of, 866 
causes of, 866 
atelectasis as cause of, 866 
extent of, 866 
condition of skin in, 866 
oedema in, 867 
temperature in, 867 
peculiar cry in, 867 
general symptoms of, 867 
symptoms of in later life, 867 
prognosis in, 867 
diagnosis of, 868 
anatomical appearances, 868 
condition of skin in, 868 
bloodvessels in, 868 
lungs in, 869 
treatment of, 869 
Scleriasis of spinal cord in infantile pa- 
ralysis, 579 
Scrofula as sequel of hooping-cough, 238 
Season, influence upon frequency of true 
croup, 87, 599 
pneumonia and bronchitis, 

157 
diphtheria and croup, 599 
Seat-worm (see ascaris vermicularis), 871 
Second attacks of scarlatina, 670 
Secondary fever in variola, 750, 758 
See, on gymnastic exercises in chorea, 

567 
Sensibility affected in diphtheritic paraly- 
sis, 620 
Shingles (see herpes zoster), 826 
Sims, Marion, on cause of tetanus nascen- 

tium, 539 
Silver, nitrate of, in chronic entero-coli- 
tis, 374 
in dysentery, 403 
local application of in diphtheria, 

621 
in diphtheritic paralysis, 627 
local use of in scarlatinous angina, 
718 
to prevent pitting in variola, 
759 
enema of in worms, 886 
Skin, diseases of, general remarks on, 789 
examination of, 30, 31, 32 
color of, in infants, 30, 31 
in different diseases, 31 
i exudation on, in diphtheria, 605, 610 
in congenital syphilis, 659 
in scarlatina (see eruption and desqua- 
mation). 
in measles (see eruption and desqua- 
mation). 
in variola (see eruption and desqua- 
mation), 
in typhoid fever, 780 
gangrene of, in erysipelas, 797 
in sclerema, 868 
Sleep, diagnostic signs from, 23 
Small-pox (see variola), 745 



Smith, J. Lewis, on lesions in cyanosis, 
253 
on symptoms in cyanosis, 257 
state of intestine in entero-colitis, 

350 
on liver in entero-colitis, 354 
Snuffles, 52 

morbid, 52, 54 
Soaps in treatment of eczema, 823, 824 
Soda, hyposulphite of, in scarlatina, 710 

in favus, 857 
Softening of stomach, 338 

of bones in rickets, 610 
Soreness of body in rickets, 635 
Sounds of heart, 36 
respiratory, 44 
Spasm of glottis (see laryngismus stridu- 
lus), 512 
carpo-pedal, 519, 530 
Spence, J., on tracheotomy in croup, 109 
Sphincters affected in chorea, 555 
Spigelia as vermifuge, 881 
Spinal cord in tetanus, 541 
in chorea, 552 
in infantile paralysis, 578 
column, alteration of, in rickets, 637 
Spiritus saponatus kalinus, 823 
Spleen, enlarged in typhoid fever, 781 
Squamae, chapter on, 846 
rare in children, 846 
Statistics of frequency and mortality of 
pneumonia, 153, 157, 180 
of bronchitis, 157, 189 
of pleurisy, 221 

after paracentesis in pleurisy, 226 
of true croup, 86, 597, 599 
after tracheotomy in true croup, 

103-109 
of hooping-cough, 230 
of thrush, 296 
of entero-colitis, 342 
of cholera infantum, 344, 379 
of nervous diseases, 435 
of tubercular meningitis, 436 
of eclampsia, 494 
of tetanus nascentium, 540 
of chorea, 547, 561 
of diphtheria as compared with 

true croup, 86, 597, 599 
of rickets, 632 
of scarlatina, 665, 702 
of rubeola, 665, 723 
of variola, 745, 746 
of variola after vaccination, 770 
of typhoid fever, 785 
Stimulus, indications for, in pneumonia, 
185 
use of, in entero-colitis, 369 

in stage of collapse in cholera in- 
fantum, 394 
in chorea, 565 
in diphtheria, 626 
in scarlatina, 716 
in variola, 758 
in typhoid fever, 787 
in erysipelas, 802 






916 



INDEX, 



Stomach and intestines, general remarks 
on diseases of, 315 
functional disease of (see indiges- 
tion), 316 
diseases of, attended with lesions, 
336 

inflammation of (see gastritis), 336 

condition in entero-colitis, 354 

eruption on, in variola, 755 
Stomatitis. 

in congenital s} T philis, 660 

in small -pox, 749 
erythematous. 

article on, 268, 269 

definition and frequency of, 268 

causes of, 269 

symptoms of, 269 

treatment of, 269 
follicular. 

article on, 269-272 

definition, synonymes, frequency of, 
269 

forms of, 270 

symptoms and duration of, 270 

diagnosis of, 270 

prognosis in, 271 

treatment of, 271 
ulcerative or ulcero-membranous. 

article on, 272-276 

definition, synonymes, frequency of, 
272 

causes of, 272 

symptoms and course of, 273 

duration of, 274 

diagnosis of, 274 

prognosis in, 274 

treatment of, 274 
gangrenous. 

article on, 276-287 

definition, synonymes, frequency of, 
276 

causes of, 277 

anatomical lesions of, 277 

symptoms and course of, 279 

duration of, 281 

diagnosis of, 281 

prognosis in, 282 

treatment of, 283 
Stools, diagnostic signs from the, 50 

in simple diarrhoea, 331 

in acute entero-colitis, 356 

in chronic entero-colitis, 360 

in cholera infantum, 387, 388 

bloody, in intussusception, 425 

in typhoid fever, 778, 779, 781 

in case of worms, 877 
Straw-fungus as cause of rubeola, 725 
Strophulus. 

article on, 842,843 

definition of, 842 

causes of, 842 

varieties and symptoms of, 842 

diagnosis of, 842 

treatment of, 843 

intertinctus or red gu?n, 842 

covjertus, 842 



Strophulus albidus or white gum, 842 
Strychnia in chorea, 565 

in infantile paralysis, 583 

in diphtheritic paralysis, 627 
Sucking, signs from mode of, 48 
Sugar in urine in hooping-cou"h, 234 
Sulphurous baths in chorea, 566 

applications in favus, 857 
Sulphur in treatment of scabies, 832 
Suppurative fever in variola, 750, 758 
Swine-pox (see varicella). 
Sympathetic nerve, affection of, in cholera 

infantum, 385 
Syphilis, congenital, article on, 658-664 

modes of transmission of, to embryo, 
658 

date of appearance of symptoms, 659 

condition of skin in, 659 

pemphigus and other eruptions in, 
659 

coryza and stomatitis in, 660 

alteration of voice in, 660 

rhagades and condylomata in, 660 

course of, 661 

development of tertiary stage, 661 

alteration of teeth in, described by 
Hutchinson, 661 

interstitial keratitis in, 662 

affection of internal organs in, 662 

anatomical lesions in, 662 

diagnosis of, in early stage, 662 
in later stage, 663 
between inherited and acquired, 
663 

prognosis in, 663 

treatment of, 663 

use of mercury in, 663 
Syphilis, transmitted by vaccination, 768 



Tabes mesenterica (see tuberculosis of 

mesenteric glands), 646 
Table of mortality (see statistics). 
Tache meningitique in meningitis, 447 
Tape- worm (see Taenia), 871, 872 
Tarry applications in eczema, 824 
in scabies, 833 
in tinea, 862 
in favus, 858 
Tartar emetic (see antimony). 
Tears, arrest of in disease, 27 
Teeth, alteration of in congenital syphi- 
lis, 661 
Temperature, normal at different ages,* 
37 
effect of, on mortality of pneumonia 

and bronchitis, 157 
of body, low in cyanosis, 257 
in tubercular meningitis, 449 
lowered in infantile paralysis, 574 
in acute rheumatism, 5dl, 592 
influence of, upon disease, 87 
effect upon mortality of diphtheria 

and croup, 598 
in pulmonary phthisis, 650 
in scarlatina, 676, 677 



INDEX. 



917 



Temperature in measles, 729, 730 

in typhoid fever, 778, 779, 780 

high, as cause of lichen, 848 

in sclerema, 867 

proper for sick-room, 741 
Tenotomy in infantile paralysis, 585 
Testicle, afl'ected bv metastasis in mumps, 

631 
Tetanus nascentium, article on, 588-546 

definition and synonymes of, 588 

period of occurrence of, 539 

morbid conditions of umbilicus as 
cause of, 539 

Sims's view of displacement of occipi- 
tal bone as cause of, 539 

general causes of, 539 

frequency of, ■ 40 

anatomical lesions in, 540 

microscopic changes in spinal cord 
in, 511 

symptoms of, 542 

occurrence of paroxysm in, 543 

prognosis in, 543 

diagnosis of, 544 

duration of, occasionally chronic, 544 

prophylaxis in, 544 

treatment of, 545 

anaesthetics in, 545 

narcotics and antispasmodics in, 546 
Thermometer, observations with, in chil- 
dren, 37 
Thread-worm (see ascaris vermicularis), 
871 

(see tricocephalus dispar), 871 
Throat, diseases of (see pharyngitis), 268 
Thrush, article on, 287-310 

definition, synonymes of, 287 

frequency of, 288 

predisposing causes of, 288 

exciting causes of, 289 

anatomical lesions of, 289 

description of fungus of, 291 

symptoms of, 291 

nature of, 296 

diagnosis of, 296 

prognosis in, 296 

general treatment of, 297 

examination of cow's milk, 298 

mode of preparation of cow's milk, 301 

quantity of food necessary for chil- 
dren, 302 

formula for gelatine food, 304 

examination of mother's milk, 306 

diet in, 307 

remedies useful in, 308 

local treatment of, 809 
Thymus gland, enlarged in laryngismus 

stridulus, 515 
Tinea lactea (see eczema capitis), 812 

granulata (see eczema granulatum), 
814 

decalvans (see alopecia areata), 864 
tricophytina, varieties of, 858 

identity of t. tonsurans and t. circi- 
nata, 858, 859 

synonymes of, 858 



Tinea tricophytina, description of its fun- 
gus, tricophyton, 850 

contagion as cause of, 858 

other causes of, 858 

general treatment in, 861 

local treatment in, 861 

epilation in, 861 

alkaline applications in, 861 

mercurial applications in, 861 

tarry applications in, 862 

cases of, 862 
tonsurans. 

eruption in, 859 

character of hairs in, 859 

condition of scalp in, 860 

diagnosis of, 860 

prognosis of, 860 
circinata. 

eruption in, 860 

character of hairs in, 861 

diagnosis of, 861 
Tongue in scarlatina, 674, 675 
Tonsil, sloughing of, in diphtheria, 604 

condition of, in scarlatina, 684 
Tracheotomy, in membranous croup, 103 

statistics of its performance in differ- 
ent countries, 103-107 

influence of epidemic constitution 
. upon results of, 105 

estimation of its value, 107 

dangers of the operation, 107 

rules to guide in advising, 108 

proper period for performing, 109 

indications for, 110 

influence of period of performance 
upon result, 110 

contraindications, 111-114 

age as a contraindication, 111 

successful cases at early age, 111 

extension of false membrane into the 
bronchia as a contraindication, 
111 

negative results of auscultation, 112 

presence of pneumonia as a contrain- 
dication, 1 13 
general diphtheria as a contrain- 
dication, 113 

contraindicated in secondary forms of 
croup, 113 

twice successfully performed in same 
subject, 114 

mode of performing, 115-119 

instruments required in performing, 
115 

details about canulas, 115 

substitutes for canulas, 116 

question of fixing trachea in, 117 
excising piece of trachea in, 117 

mode of performing, 117 

emphysema of neck following, 118 

use of ansestheties during, 118 

after treatment, 119-124 

great importance of, 119 

modes of rendering inspired air moist, 
119 

treatment of wound, 120 



59 



918 



INDEX. 



Tracheotomy, instillation and atomization 
into trachea after, 120 

directions for cleansing tabes after, 121 

mode of removing canula, 121 

date of removing canula, 122 

causes of delay in removing canula, 
122 

general after-treatment, 122 

importance and manner of feeding- 
patients, 122 

question of medication after, 123 

difficulty of deglutition following, 123 

illustrative cases of, 124 
Treatment of coryza, 57 

of simple laryngitis without spasm, 66 

of chronic laryngeal cough, 66 

of spasmodic simple laryngitis, 78 

of pseudo-membranous laryngitis, 96 

of atelectasis pulmonum, 137 

of collapse of the lung, 150 

of pneumonia, 179 

of bronchitis, 204 

of pleurisy, 221 

of hooping-cough, 240 

of complications in, 247 
of paroxysm of, 250 

of cyanosis, 259 

of acute pericarditis, 262 

of chronic pericarditis, 262 

of acute endocarditis, 263 

of chronic valvular disease, 264 

of erythematous stomatitis, 269 

of aphthae, 271 

of ulcerative stomatitis, 274 

of gangrene of the mouth, local, 283 
general, 287 

of thrush, 297 

of simple pharyngitis, 314 

of indigestion, 321 

of simple diarrhoea, 332 

of gastritis, 340 

of entero-colitis, 361 

of cholera infantum, 391 

of dysentery, 401 

of diseases of coecum and appendix, 417 

of intussusception, 431 

of tubercular meningitis, 455 
' of simple meningitis, 469 

of cerebral congestion, 475 

of cerebral hemorrhage, 482 

of chronic hydrocephalus, 490 

of eclampsia, 505 

of laryngismus stridulus, 522 

of contraction with rigidity, 532 

of tetanus nascentium, 544 

of chorea, 562 

of atrophic infantile paralysis, 582- 
586 

of facial paralysis, 587 

of progressive paralj-sis, with appar- 
ent hypertrophy of muscles, 590 

of acute rheumatism, 593 

of diphtheria, 621 

of mumps, 631 

of rickets, 641 

. of tuberculosis, 656 



Treatment of congenital syphilis, 663 
of scarlatina, 707 
of scarlatinous dropsy, 719 
of measles, 740 
of variola, 757 
of varicella, 775 
of typhoid fever, 786 
of erythema, 793 
of erysipelas, 799 
of roseola, 806 
of urticaria, 808 
of eczematous affections, 818 
of herpes, 828 
of scabies, 832 
of pemphigus, 835 
of rupia, 838 
of ecthyma, 841 
of strophulus, 843 
of lichen, 844 
of prurigo, 845 
of psoriasis, 847 
of pityriasis, 847 
of ichthyosis, 847 
of favus, 855 
of tinea, 861 
of alopecia areata, 865 
of sclerema, 869 
of ascaris lumbricoides, 880 
of ascaris vermicularis, 886 
Tricophyton, description of (see tinea also), 

850 
Trismus (see tetanus). 
Trousseau, on tracheotomy in true croup, 
104, 105, 110, 113 
on paracentesis, 223-228 
on compression of the head in hydro- 
cephalus, 492 
Tube-casts in urine in diphtheria, 616 

in scarlatina, 697 
Tuberculosis, as sequel of typhoid fever, 
784 
of measles, 737 
of hooping-cough, 238 
of meninges (see meningitis), 436 
article on, 643-658 
causes of, 643 

relation of, to pneumonia, 643 
apt to involve several viscera simul- 
taneously, 643 
of bronchial glands, anatomical ap- 
pearances of, 643 
of lungs, anatomical appearances of, 

644 
of peritoneum, anatomical appear- 
ances of, 645 
of omentum, anatomical appearances 

of, 645 
of mesenteric glands, anatomical ap- 
pearances of, 646, 647 
term used to include cheesy products 

not strictly tuberculous, 647 
of bronchial glands, symptoms of, 647 
characters of cough in, 648 
pressure on veins in, 648 
physical signs of, 648 
peculiarities of, 649 



INDEX. 



919 



Tuberculosis, pulmonary, symptoms of, 
649 
importance of general symptoms 

in, 650 
character of cough in, 650 
haemoptysis rare in, 650 
temperature in, 650 
peculiarities of physical signs in, 

651 
pneumonia in, 652 
duration of, at times great, 652 
occasional recovery in, 652 
of peritoneum, symptoms of, obscure 
652 
digestive disturbances in, 652 
pain in, 653 

enlargement of abdomen in, 653 
tumor when omentum is affected, 

653 
course of, 653 
modes of death in, 653 
of mesenteric glands, symptoms of, 
653^ 
enlargement of abdomen in, 

654 
detection of tumor in, 654 
digestivedisturbancesin,654 
duration of, 654 
diagnosis of, 654 

from remittent fever, 655 
from typhoid fever, 785, 786 
pulmonary, diagnosis of, from chronic 

bronchitis, 655 
of peritoneum, diagnosis of, from sim- 
ple distension of abdomen, 655 
of mesenteric glands, diagnosis of, 

from abdominl tumors, 655 
prognosis in, 655 
possibility of recovery from, 656 
modes of death in, 656 
treatment of, prophylactic, 656 

curative, 656 
use of tonics in, 657 
diet in, 657 
cod-liver oil in, 657 
treatment of complications, 658 
Tuberculous pneumonia, 652 

peritonitis (see tuberculosis of perito- 
neum). 
Tuckwell, on chorea, 548 
Tumor, abdominal, in diseases of coecum 
and appendix, 413 
in intussusception, 426 
in tuberculosis of mesenteric 
glands, 654 
tut 
655 

diagnosis of, 655 
of brain, as cause of hydrocephalus, 
486' 
gummy, in congenital syphilis, 662 
Turpentine as a vermifuge, 882 
Typhlitis, in article on diseases of ccecum 
and appendix, 404-419 
synonymes of, 405 
seat and character of, 405 



Typhlitis, causes of, 406 

anatomical appearances of, 409 

symptoms of, 413 

of perforation of the coecum dur- 
ing, 414 

duration of, 415 

prognosis in, 415 

diagnosis of, 416 

treatment of, 417 
Typhoid fever, diagnosis from tubercular 
meningitis, 449 

article on, 775-788 

formerly confounded with remittent 
fever, 775 

causes of, 775 

but slightly contagious, 776 

epidemic nature of, 776 

anatomical appearances in, 776 

condition of blood in, 776 

condition of brain in, 777 

tubercular meningitis after, 777 

symptoms of ordinary cases, 777 

marked remissions in febrile action, 
777 

prodromes in, 777, 780 

eruption in, 778, 782 

symptoms of fully developed attack, 
778 
of grave cases, 778 

favorable symptoms in, 779 

unfavorable symptoms in, 780 

digestive disturbances in, 777, 778, 
780 

character of stools in, 781 

distension of abdomen in, 781 

enlargement of spleen in, 781 

urine in, 781, 783 

respiration in, 778, 782 

pulse in, 782 

nervous symptoms in, 782, 783 

pulmonary complications in, 783 

perforation of intestine in, 783 

intestinal hemorrhage in, 783 

albuminuria and oedema in, 783 

complicated with malaria or one of 
the eruptive fevers, 784 

tuberculosis as sequel of, 784 

convalescence in, 784 

relapses in, 779, 784 

duration of, 784 

prognosis and mortality, 784 

diagnosis of, from gastro-enteritis, 
785 
from typhoid pneumonia, 785 
from acute tuberculosis, 785 

treatment of febrile symptoms in, 
786 
of gastric irritability in, 786 
of intestinal symptoms in, 787 
of nervous symptoms in, 787 
of complications in, 787 

use of quinia in, 787 
opium in, 787 
stimulants in, 787 

diet in, 788 

management of convalescence, 788 



920 



INDEX. 



Ulceration of internal malleoli in thrush, 
295 

of mucous membrane of fauces in diph- 
theria, 603 
in scarlatina, 684 

in erythema intertrigo, 791, 792 
Umbilicus, morbid states of, as cause of 

tetanus, 589 
Umbilication of variolous pock, cause of, 

755 
Uraemia, in scarlatinous dropsy, 695, 696 
Urine in pneumonia, 174 

in bronchitis, 202 

in pleurisy, 217 

in hooping-cough, 234 

in chorea, 556 

in diphtheria, 612 

in rickets, 635 

in scarlatina, 675 

in scarlatinous dropsy, 697 

in measles, 729 

in variola, 751 

in typhoid fever, 781, 783 
Urticaria. 

article on, 806-809 

definition and synonymes of, 806 

forms of, 806 

causes of, 806 

symptoms of, 807 

diagnosis of, 808 

prognosis in, 808 

treatment of, 808 



Vaccina (see vaccine disease). 
Vaccination (see under vaccine disease). 
Vaccine disease, article on, 762-772 
definition and synonymes of, 762 
history of, 762 
date of appearance and development 

of pock, 763 
cellular character of pock, 763 
local and general symptoms in, 764 
desiccation and desquamation in, 764 
character of cicatrix after, 764 
irregularities and course of, 764 
severe local symptoms in, 765 
erysipelas following, 795 
appearance of pock retarded, 765 
spurious form of, 765 
diagnosis of, 766 

protective power of against variola, 
766 
against death, 770 
Vaccination, period of performing, 767 
susceptibility to, variable, 767 
effect of cutaneous eruptions on, 768 
alleged transmission of cutaneous dis- 
eases by, 768 
of syphilis by, 768 
forms of virus employed, 769 
characters of good vaccine crust, 769 
modes of introducing virus, 769 
advantages of several punctures in, 
770 



Vaccination, influence of number and 
quality of cicatrices on mortality 
after, 770 
place of performing, 770 
Revaccination, necessity for, 771 
results of, 772 
period of performance, 772 
Vaccinia (see vaccine disease). 
Vacuole (see bronchial abscess), 193 
Valerian, in chorea, 564 
Valleix,plan of examining abdomen, 46 
expectoration in true croup, 93 
emetics in true croup, 98 
on tracheotomy in croup, 107 
expectoration in pneumonia, 172 
Valvular diseases of heart (see heart). 
Varicella, article on, 772-775 
definition of, 772 
synonymes of, 773 
forms of, 773 
contagious nature of, 773 
epidemic nature of, 773 
essentially distinct from variola, 773 
symptoms of, 773 
eruption in, 773 
diagnosis of, 774 
prognosis in, 774 
treatment of, 775 
Variola, article on, 745-761 
definition of, 745 
frequency of, 745 
forms of, 746 
contagious nature of, 747 
epidemic nature of, 747 
transmitted by fomites, 747 
regular form of, period of incubation 
in, 747 
symptoms of initial stage, 747 
pain in the loins in, 747 
symptoms of eruptive stage of, 

748, 750 
discrete and confluent forms, 748 
date of appearance of eruption in, 
and character of papules in, 748 
development of eruption in, 748 
occurrence of eruption on mucous 

membranes, 749 
stomatitis in, 749 
laryngitis in, 749 
swelling of subcutaneous tissue 

in, 750 
subsidence of general symptoms 
on appearance of eruption, 750 
secondary fever, 750 
date of desiccation, 750 
date and modes of desquamation, 

751 
pitting after, 751 
digestive symptoms during, 751 
urine in, 751 

excessive discharge of urine dur- 
ing desiccation, 752 
nervous symptoms in, 752 
irregular forms of, symptoms of in- 
itial stage, 752 
course of eruption in, 753 



INDEX, 



921 



Variola, irregular forms of, hemorrhagic 
eruption in, 753 
no subsidence of fever in, 753 
modified (see varioloid), 753 
complications of, 754 
anatomical lesions, 755 
condition of blood in, 755 

mucous membranes in, 755 
anatomy of pock in, 755 
diagnosis of, 756 
prognosis in, 756 
favorable symptoms in, 756 
unfavorable symptoms in, 757 
treatment of, 757-761 
mild febrifuges in mild cases, 757 
laxatives in, 757 
bleeding in, 758 
remedies for favoring appearance of 

eruption in, 758 
diet in, 758 
quinia in, 758 
opium in, 758 
stimulants in, 758 
treatment of complicationsin, 758 

of ophthalmia, 759 
prevention of pitting in, 759-761 
cauterization of pock with nitrate of 

silver, 759 
mercurial applications in, 760 
applications of solution of gutta per- 
cha in, 761 
Varioloid, definition of, 753 
symptoms of, 754 

course of eruption more rapid in, 754 
absence of secondary fever in, 754 

no pitting after, 754 
duration of, 754 
prognosis in, 756 
Venesection (see bleeding). 
Ventilation, importance of, in sick-cham- 
ber, 741 
Vermifuges, 881-885 
Vesicles, chapter on, 809 

in variola, 749 
Virus, vaccine, forms of employed, and 

mode of introduction, 769 
Viscera, peculiar changes of in rickets, 

640 
Voice, alteration of in coryza, 57 



Voice, alteration of in simple laryngitis, 63 
in false croup, 77 
in true croup, 91, 92 
in diphtheritic paralysis, 619 
in congenital syphilis, 660 
Volvulus (see intussusception), 419 
Vomicaa, rare in tuberculosis of lungs, 644 
Vomiting, diagnostic signs from, 49, 50 
in gastritis, 339 
in entero-colitis, 358 
remedies for, 371 
in cholera infantum, 388 

treatment of, 393 
in intussusception, 425 
in typhoid fever, 777, 778 



Water, importance of administering in 
pneumonia, 187 
in cholera infantum, 394 
external use of, in scarlatina [see also 

bath and affusion), 707, 711 
local use of, in eczema, 820 
"Wells, case of chronic trismus, 544 
West, C, on statistics of pneumonia, 153 

on cerebral congestion, 473. 
Wilson, Erasmus, description of acarus 

scabiei, 831 
Woodward, J. J., on lesions in diarrhoea, 
329 
microscopic changes in intestine in 

entero-colitis, 353 
use of calomel in diarrhoea, 365 
Woorara in tetanus, 545 
Worms in the alimentary canal, chapter 
on, 870-887 
varieties of, 870 

description of ascaris lumbricoides, 
870 
of ascaris vermicularis, 871 
of tricocephalus dispar, 871 
of taenia solium, 871 
lata, 872 
frequency of, much exaggerated, 872 
dangerous symptoms from, 873 
Wormseed oil as vermifuge, 881, 886 



Zona (see herpes zoster), 826 



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SIXTH AMERICAN EDITION, REVISED AND IMPROVED. 

Comprising a copious Veterinary Formulary, numerous Receipts of Patent 
and Proprietary Medicines, Druggists' Nostrums, etc.; Perfumery and 
Cosmetics, Beverages, Dietetic Articles and Condiments, Tirade Chemicals, 
Scientific Processes, and an Appendix of Useful Tables, by Henry 
Beasley, Author of the Booh of Prescriptions, etc., etc. Sixth American 
from the Last London Edition. Octavo $3.50 

"This is one of the class of books that is indispensable to every Druggist and Pharmaceutist as a hook of 
reference for such information as is wanted, not contained in works used in the regular line of his business, 
and we can recommend it as one of the best of the kind." — American Druggists' Circular. 



Barth & Roger's Manual of Auscultation and 
Percussion. 

A new American Translation from the Sixth French Edition. 16mo. $1.25. 

" This is one of the most useful and practical manuals of its sort that has ever yet appeared, and we can- 
not toe strongly recommend it to every student of medicine. It is sufficiently comprehensive without being 
lengthy, and the principles, which are eminently sound, can easily be mastered and understood." — Medical 
Record. 

Bouchardat's Annual Abstract 

Of Therapeutics, Materia Medica, Pharmacy, and Toxicology, 
for 186*1, with an Original Memoir of Gout, Gravel, Urinary Cal- 
culi, &c. By A. Bouciiakdat, Professor of Hygiene to the Faculty 
of Medicine, Paris, &c. Translated and Edited by M. J. De Rosset, 
M.D., Adjunct to the Professor of Chemistry in the University of 
Maryland. In one Volume. Price, in cloth, . . $1.60. 



LINDSAY AND BLAKISTON 7 S PUBLICATIONS. 

Andrews' Hand-Book of the Practice of 

Medicilie. In Preparation. 

Bull on the Maternal Management of Chil- 
dren in Health and Disease. 

A New and Improved Edition. By Thomas Bull, M.D., Member of the 
Royal College of Physicians. 12mo $1.25 

Biennial Retrospect of Medicine, Surgery, 
and their Allied Sciences, containing: — 

1. Report on Physiology, by Henry Power, F.R.C.S., M.B. Lond. 

2. Report o.v Practical Medicine, by Francis Edmund Anstie, M.D., etc. 

3. Report on Surgery, by T. Holmes" Esq., M.A., F.R.C.S., etc. 

4. Report on Ophthalmic Medicine and Surgery, by Thomas Windsor, M.D. 

5. Report on Midwifery and the Diseases op Women and Children, by R. Barnes, 
M.D., F.R.C.P. 

6. Report on Medical Jurisprudence, by C. Hilton Fagge, M.D., F.R.C.P. 

7. Report on Materia Medica and General Therapeutics, by C. Hilton Fagge, M.D., 
F.R.C.P. 

S. Report on Public Health, by C. Hilton Fagge, M.D., etc. 

In One Volume Octavo. Price, . $3.50 

"This volume, published under the auspices of the New Sydenham Society, now makes its welcome appear- 
auce biennially instead of yearly, as heretofore. It is the most carefully prepared retrospect with which 
we are acquainted. Each department is in charge of a gentleman of reputation, and everything is done to 
summarize, in a very readable way, all the more important advances of medicine over the globe. It is hand- 
BOiuely bound and elegantly printed." — iV. Y. Medical Record. 

Birch on Constipation. Third Edition. 

CONSTIPATED BOWELS; the various Causes and the Different 

Means of Cure. By S. B. Birch, M. D., Member of the Royal College 

of Physicians of London, &c. The Third Edition. One volume, 16mo. 

Price, $1.25 



Braithwaite's Epitome of the Retrospect of 
Practical Medicine and Surgery. 

Two large Octavo Yolunies of 900 pages each, . . . $10.00 

Braithwaite's Retrospect of Practical Medi- 
cine and Surgery. 

"The cream of medical literature." 

Published half-yearly, in January and July, at $2.50 per annum, if paid in 
advance; or 81.50 for single parts. 



LINDSAY AND BLAKISTON S PUBLICATIONS. 



British and Foreign Medico-Chirurgical Re- 
view, and Quarterly Journal of Practical 
Medicine and Surgery. 

Published in London on the 1st of January, April, July, and October, at 
6 shillings per number, or 24 shillings per annum, and furnished in this 
country at $10.00 per annum; being much less than the present cost of 
importation of English books. Containing Analytical and' Critical Re- 
views, a Bibliographical Record, Original Communications, and a Chron~ 
icle of Medical Science, chiefly Foreign and Contemporary. 

This is considered the leading Medical Review in the English language. It is every- 
where looked upon as high authority. It presents in its pages a large amount of valu- 
able and interesting matter, and will post the physician who reads it, fully up to ihe 
present day in medical literature. 

Chambers's Lectures. The Renewal of Life. 

Second American from the Fourth London Edition. 

Lectures chiefly clinical, illustrative of a Restorative System of Medicine. 
By Tiios. K. Chambers, M. D., Physician to St. Mary's Hospital. 
Author of " The Indigestions," &c, &c. Octavo, . . $5.00 

" The medical profession in this country are under obligations to the American publishers 
for this reprint of Dr. Chambers' Lectures — a work whose time is forever, everywhere in its 
place, admirable in tone, full of valuable instructions and practical teachings, and written in 
clear, compact, and ofteu epigrammatic English. We can oiler but a brief notice of this intrin- 
sically good book, which is certain of finding a wide circle of readers, and we should hope a 
place in every medical library." — Xeio York Medical Journal. 

"This work is of the highest merit, written in a clear, masterly style, and devoid of technicalities- It is 
simply what it professes to be, Lectures Clinical, delivered from cases observed at the bedside; therefore 
more valuable as enunciating the views and experiences of a practical miud aided by actual observation. 

They are of deep interest, and replete with facts having a practical bearing, and will well repay perusal 

YVe can recommend Dr. Chambers' book freely and with confidence, as the work of a great mind practical in 
its bearing, and simple to the uuderstauding of all." — Canada Medical Journal. 

Chew on Medical Education. 

A Course of Lectures on the Proper Method of Studying Medicine. By 
Samuel Chew, M.D., Professor of the Practice and Principles of 
Medicine and of Clinical Medicine in the University of Maryland. 
12mo 81.00 

"The topics discussed in this volume are of books — of time to be devoted to study — and the manner — of 
the order of medical studies — of the taking of notes — of clinical instruction — dissections — auscultation — 
Hi6dical schools, &c. 

"Dr. Chew was an eminent member of the medical profession, and a well-Known teacher of medicine, lie 
was. therefore, well fitted for the judicious performance of this task, upon which he seems to have entered 
<vith interest and pleasure. It is a well-timed book, and will serve as a most excellent manual for the student 
is well aa a refreshing and suggestive one to the practitioner." — Lancet and Observe) . 
2 



Cazeaux's Great Work on Obstetrics. 

Fifth American from the Seventh French Edition. AVith 175 Illustrations. 

A Theoretical and Practical Treatise on Midwifery. Including the Dis- 
eases of Pregnancy and Parturition, and the attention required by the 
Child from its Birth to the Period of Weaning. By P. Cazeaux, 
Member of the Imperial Academy of Medicine, Adjunct Professor in 
the Faculty of Medicine of Paris, &c, &c. Bevised and annotated 
by S. Tarnier, Adjunct Professor to the Faculty of Medicine, Paris, 
&c, etc. Translated by W. R. Bullock, M. D. With new Litho- 
graphic and other Illustrations on Wood. One volume Royal Octavo, 
of over 1100 pages. 

Price, bound in Cloth, Bevelled Boards, .... $6.50 
Leather, . . . . . . 7.50 

'•Written expressly for the use of students of medicine, and those of midwifery especially, its teachings are 
plain and explicit, presenting a condensed summary of the leading principles established by the masters of 
tee obstetric art, and such clear, practical directions for the management of the pregnant, parturient, and 
pne, ->era! states, as have been sanctioned by the most authoritative pi'actitioners, and confirmed by the 
author s own experience. Collecting his materials from the writings of the entire body of antecedent writers, 
carefully testing their correctness and value by his own daily experience, and rejecting all such as were falsi- 
fied by the numerous cases brougbt under his own immediate observation, he has formed out of them a body 
of doctrine, and a system of practical rules, which he illustrates and enforces in the clearest and most simple 
manner possible.''* — Examiner, 

CannifFs Manual of the Principles of Surgery. 

Based on Pathology, for Students, by Wm. Canniff, Licentiate of the 
Medical Board of Upper Canada; M.D. of the University of New 
York ; M.R. C.S. of England ; formerly Souse Surgeon to the Seamen's 
Hospital, New York; late Professor of General Pathology and the 
Principles and Practice of Surgery, University Victoria College. C. W. 
Octavo $4.50 

'"This manual is evidently the production of a man who is well informed on his subject, and who moreover 
has had experience as a teacher and as a practitioner. lie has profited by the study of the best authors on 
the principles of surgery, tested practically their doctrines, and has presented his own views, well arranged 
and clearly expressed, for the advantage of others." — American Journal of Med. Science. 

CleavelancT s Pronouncing Medical Lexicon. 

A NEW AND IMPROVED EDITION (THE ELEVENTH). 

Containing the Correct Pronunciation and Definition of most of the Terms 
used by Speakers and Writers of Medicine and the Collateral Sciences. 
By C. H. Cleaveland, M.D., Member of the American Medical Associa- 
tion, etc., etc. A small Pocket Volume $1.25 

This little work is both "brief and comprehensive ; it is not only a Lexicon of all the 
words in common use in Medicine, but it is also a Pronouncing Dictionary, a feature 
of great value to Medical Students. To the Dispenser it will prove an excellent aid, 
and also to the Pharmaceutical Student. This edition contains a List of the Abbrevia- 
tions used in Prescriptions, together with their meaning; and also of Poisons and their 
Antidotes: two valuable additions. It has received strong commendation both from the 
Medical Pre«s and from the profession. 



LINDSAY AND BLAKISTON'S PUBLICATION'S. 

Colien on Inhalation. 

Its Therapeutics and Practice. A Treatise on the Inhalation of Gases, Va- 
pors, Nebulized Fluids, and Powders ; including a Description of the Ap- 
paratus employed, and a Record of Numerous Experiments, physiological 
and pathological ; with Gases and Illustrations. By I. Solis Cohen, M. D. 
12ino $2.50 

"We recognize in this book the work of a persevering Physician who has faithfully studied his sub- 
ject, and added to its literature much that is useful from his own experience. It treats respectively of 
the inhalations of nebulized fluids; of medicated airs, gases, and vapors, and of powders. Dr. Cohen 
has given us briefly and cleaidy whatever is valuable in relation to the insufflation of powders in res- 
piratory affections, with the experimental proofs and pathological evidence of their penetration into 
the bronchial tubes and lung tissues." — American Journal of Medical Sciences, July, 1S6S. 

Carson's History of the Medical Department 

of the University of Pennsylvania, from its foundation in 1765, with illus- 
trative sketches of Deceased Professors, &c, &c. By Joseph Carson, M.D., 
Professor of Materia Medica and Pharmacy in that Institution. Octavo. 

Price, $3.00. 

"rh'^rsn an ih a TTtt^ \ A New Edition, thoroughly Eevised, and a great 

uiAou on wie n.ye. | portion Ee _ writteni 

A Guide to the Practical Study of Diseases of the Eye, with an Outline of 
their Medical and Operative Treatment, with Test Types and Illustrations. 
By James Dixon, F. R. C. S., Surgeon to the Royal London Ophthalmic 
Hospital, &c, &c. In one volume. Price, $2.50 

OPINIONS OF THE PRESS. 

"We strongly recommend this book to the perusal of the profession, because it contains the results 
of much careful observation ; and, for the student, we have seen no work better adapted as a practical 
introduction to the study of ophthalmic diseases."— Medical Times and Gazette. 

" We must content ourselves with expressing our strong conviction that this is a work of 

sterling and permanent value, carrying all the weight that belongs to j'cars of skilful experience, and 
deserving, even as a handbook, to rank with the best practical monographs in our language." — The 
Lancet. 

" We have no hesitation in reiterating our strong commendation of Mr. Dixon's work, and urging 
its study upon those of our readers who are desirous of obtaining sound information on the important 
branch of medical science to which it relates." — British and Foreign Medico- Ohirurgical Review. 

" Mr. Dixon's book is essentially a practical one, written by an observant author, who brings to bis 
special subject a sound knowledge of general Medicine and Surgery." — Dublin Quarterly. 

" Our object is not to review but to recommend this work to Students, with the confident assurance 
that they will rarely be disappointed in their appeals to it as a reliable guide to the practical study 
of the Diseases of the Eye." — American Medical Journal. 

"We have taken great pleasure in a careful perusal of this book, which, both in style and matter, is 
unsurpassed in any language. It embraces quite a wide range of topics, and furnishes a very valu- 
able practical guide in the medical and surgical treatment of diseases of the eye." — Buffalo Medical 
Journal. 



LINDSAY AND BLAKISTON'S PUBLICATIONS. 



Durkee on Gonorrhoea and Syphilis. 

The Fifth Edition, Revised and Enlarged, with Portraits and Colored 

Illustrations. 

A Treatise on Gonorrhoea and Syphilis. By Silas Durkee, M.D., Fel- 
low of the Massachusetts Medical Society, &c, &e. A New and Revised 
Edition, with Eight Colored Illustrations. Octavo. . . $5.00 

This work of Dr. Dukkee's has received the unqualified approval 
of the Medical Press and the Profession both in this country and in 
Europe. The author has devoted himself especially to the treatment of 
this class of diseases, and his 25 or 30 years experience in doing so is 
here recorded. No one reading his work can fail in receiving very 
valuable information from it. 

" It is the work of a practical man, the subject is treated in a plain, shrewd manner. The 
hook is a good one, and the therapeutics are laid down with discrimination." — London Medical 
Times and Gazette. 

"Dr. Durkoo's production ia one of those, the perusnl of which impresses the reader in favor of the author. 
The general tone, the thorough honesty everywhere evinced, the philanthropic spirit observable in many pas- 
sages, and the energetic advocacy of professional rectitude, speak highly of the moral excellence of the 
writer: nor is the reader less attracted by the skill with which the book is arranged, the manner in which 
th c facts are cited, the clever way in which the author's experience is brought in, and the lucidity of the 
reasoning, the frequent and extremely fair allusions to the labors of others, and the care with which the the- 
rapeutics of venerea] complaints are treated." — Lancet. 

Fuller on Rheumatism, Rheumatic Gout, and 
Sciatica. 

Their Pathology, Symptoms, and Treatment By Henry William 
Fuller, M.D., Fellow of the Royal College of Physicians, London; 
Physician to St. George's Hospital, etc. From the last London Edition. 
Octavo $3.00 

Graves' Clinical Lectures on the Practice of 

Medicine. By Robert James Graves, M.D., F.R.S., Professor 
of the Institutes of Medicine in the School of Physic in Ireland. Edited 
by J. Moore Meligan, M.D. From the Second Revised and Enlarged 
Edition. Complete in One Volume. Octavo. Price, . . $0.00 

Golf's Combined Day-Book, Ledger, and Daily 

Register of Patients, combining not only the Accuracy and Essential 
Points of a regular Day-Booh and Ledger System, without any of the 
labor and responsibility, but is also a Daily Register of Patients, dV., &c. 
A large Quarto Volume, strongly bound in half-russia. Price, $12.00 
The advantages of this book are — The account of a whole family for an entire year can 
be kept in a very small space. (See Mitchell's account.) No transfer of accounts 
from one book to another, or from one part of the book to another. No protracted 
search for an account when wanted. Shows the exact state of an account at any 
moment. 



LINDSAY AND BLAKISTON S PUBLICATIONS. 

Gross' American Medical Biography of the 
Nineteenth Century. 

Edited by Samuel D. Gross, M.D., Professor of Surgery in the Jefferson 
Medical College, Philadelphia, &c., &e. With a Portrait of Benjamin 
Rush, M.D. Octavo. ........ $3.50 

Greenhow on Bronchitis, especially as connected with 

Gout, Emphysema, and Diseases of the Heart. By E. Headlam Green- 
how, M.D., Fellow of the Royal College of Physicians, &c, &c. 

Price, 82.25 

li In vivid pictures of the sort of cases which a practitioner encounters in his daily walks, and in examples 
of the way in which a student ought to turn them over in his mind and make them tools for self-improve- 
ment, we have rarely seen a volume richer." — Brit, and For. Medico-Cldrurg. Review. 

Garratt's (Alfred C.) Guide for Using Medical 
Batteries. 

Showing the most approved Apparatus, Methods, and Pules for the Medical 
Employment of Electricity in the Treatment of Nervous Diseases, &c, &c. 
With numerous Illustrations. One Volume, octavo. . . $2.00 

" The large work on the same subject, and by the same author, is pretty well known to the Profession, but 
it is bulky aud cumbrous, and by no means so practically useful. The present comparatively brief volume 
contains every thing of importance in regard to the various apparatuses useful to the Medical Electrician 
and the various modes of application for therapeutic purposes." — Lancet and Observer. 

Hewitt on the Diseases of Women. 

SECOND EDITION, REWRITTEN AND ENLARGED. 

The Diagnosis and Treatment of Diseases of Women, including the 
Diagnosis of Pregnancy. Founded on a Course of Lectures delivered 
at St. Mary's Hospital Medical School. By Graily Hewitt, M. D. 
Loncl., M. R. C. P., Physician to the British Lying-in Hospital; Lec- 
turer on Midwifery and Diseases of Women and Children at St. Marifs 
Hospital Medical School; Honorary Secretary to the Obstetrical So- 
ciety of London, &o. With a new Series of Illustrations. 
Price, in cloth, $5.00; in leather, $6.00. 

Hfllier's Clinical Treatise on the Diseases of 

Children. By Thomas Hilxier, M.D., Physician to the Hospital 
for Sick Children, and to University College Hospital, &c, &c. Octavo. 

Price, $3.00 

"Oar space is exhausted, but we have said enough to indicate and illustrate the excellence of Dr. Hillier's 
volume. It is eminently the kind of book needed by all medical men who wish to cultivate clinical acr-Vracy 
and sound practice." — London Lancet. 



LINDSAY AND BLAKISTON's PUBLICATIONS. 



Headland on the Action of Medicines in the 
System. 

By F. W. Headland, M.D., Fellow of the Royal College of Physicians, 
&c, d'c. Sixth American from the Fourth London Edition. Revised 
and enlarged. One Volume, octavo $3.00 

Dr. Headland's work lias been out of print in Ibis country nearly two years, a wilt- 
ing the revisions of the author, which now appear in this edition. It gives the onl} 
scientific and satisfactory view of the action of medicine; and this not in the way of 
idle speculation, but by demonstration and experiments, and inferences almost as in- 
disputable as demonstrations. It is truly a great scientific work in a small compass, 
and deserves to be the handbook of every lover of the Profession. It has received the 
most unqualified approbation of the Medical Press, both in this country and in Europe, 
and is pronounced by them to be the most original and practically useful work that has 
been published for many years. 

Hillc's Pocket Anatomist. 

Being a Complete Description of the Anatomy of the Human Body ; for the 
Use of Students. By M. W. Hilles, formerly Lecturer on Anatomy and 
Physiology at the Westminster Hospital School of Medicine. 

Price, in cloth, $1.00 

" in Pocket-book form, 1.25 

Heath on the Injuries and Diseases of the Jaws. 

The Jacksonian Prize Essay of the Royal College of Surgeons of Eng- 
land, 1867. By Christopher Heath, F.K. C.S., Assistant Surgeon to 
University College Hospital, and Teacher of Operative Surgery in Uni- 
versity College. Containing over 150 Illustrations. Octavo. Price, $6.00 

Hodge on Foeticide, or Criminal Abortion. 

By Hugh L. Hodge, M. D., Emeritus Professor in the University of 
Pennsylvania. A Small Pocket Volume. Price in paper covers, 30 

flexible cloth, 50 

This little book is intended to place in the hands of professional men and others the means of answering 
satisfactorily and intelligently any inquiries that may be made of them in connection with this important 
subject. 

Holmes' Surgical Diseases of Infancy and 

ChildllOOd. By J. Holmes, M.A., Surgeon to the Hospital fo- 
Silk Children, &c. Second Edition. Revised and Enlarged. Octavo. 

Price, §9.00 

Hufeland's Art of Prolonging Life. Edited by 

Erasmus Wilson, M.D., F R.S. Author of "A System of Human 
Anatomy,' 1 " Diseases of the Skin," &c, &c. 12mo. Cloth. §1.50 



LINDSAY AND BLAKISTON'S PUBLICATIONS. 

Mackenzie on the Laryngoscope, Diseases 
of the Throat, &c. Second Edition. 

The Use of the Laryngoscope in Diseases of the Throat. With additions, 
and an Essay on Hoarseness, Loss of Voice, and Stridutous Breathing 
in relation to Nervo- Muscular affections of the Larynx, by MorelT; 
Mackenzie, M.D., Physician to the Hospital for Diseases of the Throat, 
&c, &c. Second Edition, with additions, and a Chapter on the Nasal 
Passages, by J. Solts Cohen, M.D., Author of u Inhalation, Its Thera- 
peutics and Practice,''' (he. Illustrated by two lithographic plates, and 
51 engravings on wood. Octavo. Price, .... $3.00 

" While laryngoscopy was in its infancy, and before it had begun to engage to any extent the attention of 
Che Profession, it was studied with the greatest care and enthusiasm by the author of this treatise. A per- 
sonal friend of Czermak's, who has lone more than any other continental physician to introduce the laryngo- 
scope into practice, he has profited by the opp irtunities which he thus possessed of becoming acquainted with 
the anatomy and morbid anatomy of the larynx. But he has d ine much more than this. As will be seen by 
1 of this treatise, he ha- modified the instruments at present in use for the examination of the 
larynx, and has invented others for therapeutical purposes. Those who are anxious to study the diseases of 
the larynx and the mbdeof using the laryngoscop ;, cannot do better than purchase the treatise before us, as it 
is by far the best which has been published, and is thoroughly to be relied upon.'' — Glasgow Medical Journal. 

Morris on the Pathology and Therapeutics 
of Scarlet Fever. 

By Casper Morris, M.D., Fellow of the College of Physicians of Phila- 
delphia, &c. f &e. A New Enlarged Fdition. Octavo. . $1.50 

Meigs and Pepper's Practical Treatise on 
the Diseases of Children. 

Pourth Edition, thoroughly Eevised and greatly Enlar 

By J. Forsyth Meigs, M. J).. Fellow of the College of Physicians of 

Philadelphia. &c, &c.,and William Pepper, M D., Physician to the 

Philadelphia Hospital, &c, &c, forming a Royal Octavo Volume of 

over 900 pages. Price, bound in Cloth" . . . $6.00 

Leather, . . . 7.00 

Dr. Meigs' work has been out of print for some years. The rapid sale of the three previous editions, and the 

snt evidence of its _ ty: while the very 

of many years' standing of the author in the Ihildn n." imparts to it a value un- 

l, probably, by any other work on ' ct now before the Profession. This present edition has 

been almost entirely rewritten an 1 rearranged, and no effort - been spared by eifcber Drs. Meigs 

or Pepper, to make it represent fully in its most advanced state the present condition of Medicine as applied 
to Children's Diseases. 

Murphy's Review of Chemistry for Students. 

Adapted to tha Courses as Taught in the Principal Medical Schools in the 
United States. By John G. Murphy, M.D. In One Volume. 81.25. 

" This is an exceedingly well-arranged and convenient Manual. It gives the most important facts and 
principles of Chemistry in a clear and very concise manner, so as to subserve most admirably the object foi 
which it was designed." — North Western Medical and Surgical Journal. 



LINDSAY AND BLAKISTON S PUBLICATIONS. 



Maxson's Practice of Medicine. 

. A New Text-Booh on. the Practice of Medicine. By Edwin E. Maxson, 
M.D., formerly Lecturer on the Institutes and Practice of Medicine in the 
Geneva Medical College. Li One Volume. Koyal 8vo. . $4.00 

"Judging from his work, ho must be a correct observer, of plain, strong commou sense, having the pro- 
cess ami perfection of the healing art. and the amelioration of suffering, earnestly at heart, free from pre- 
judice, and open to conviction. The fact of employing, iuid thereupon recommending valuable remeuiu! 
agents, as yet, for various reasons, under the ban, and misunderstood by many physicians, is an honor to 
Him, and gives a certain additional value to his book." — American Medical Monthly. 

Mendenhall's Medical Student's Vade Mecum. 

A Compendium of Anatomy, Physiology, Chemistry, The Practice of Medi- 
cine, Surgery, Obstetrics, Diseases of the Skin, Materia Medica, Phar- 
macy, Poisons, &c, &g. By George Mendeniiall, M.D., Professor of 
Obstetrics in the Medical College of Ohio, Member of the American 
Medical Association, &c, &c. The Eighth Edition, Revised and En- 
larged ; with 224 Illustrations. ...... $2.50 

"This volume puts the student in possession of a condensed medical library. Its accuracy is a strong 
recommendation, while the portability of a volumo containing tho whole circle of medical science is a matter 
that will have weight with those for whoso service the book was originally designed. The work is offered, 
too, extremely cheap, and will be found a valuable assistant even to a well-informed practitioner of any 
branch of medicine." — Boston Medical and Surgical Journal. 

Paget's Lectures on Surgical Pathology. 

Delivered at the Royal College of Surgeons of England, by James Paget, 
F.R.S., Surgeon to Bartholomew and Christ's Hospital, d'C, d'c. The 
Third American from the Second London Edition, Edited and Revised 
by William Turner, M.B., Lond. Senior Demonstrator of Anatomy in 
the University of Edinburgh, &c., &c. In One Volume, Royal Octavo; 
with Numerous Illustrations. 

Price, in bevelled cloth, $6.00 

" in leather, 7.00 

Pennsylvania Hospital Reports. Edited by a cw- 

mittee of the Hospital Staff, J. M. DaCosta, M.D., and William Hunt. 
M.D. Vols. 1 and 2, for 186S and 1869, each volume containing upwards 
of Twenty Original Articles, by former and present Members of the 
now eminent in the Profession, with Lithographic and other Illustrations. 

Price to Subscribers, in advance, per volume, . . $4.00 

Price to Non-Subscribers, " " 

Powell's Pocket Formulary 

and Physician's Manual, embracing the Art of Conibiningand Prescribing 
Medicines. With many Valuable Recipes, Tables, &c. Bound in 
Leather, with Tucks and Pocket i 



Pereira's Physician's Prescription Book. 

• 

Containing Lists of Terms, Phrases, Contractions, anal Abbreviations, used 
in Prescriptions, with Explanatory Notes, the Grammatical Constructions 
of Prescriptions, Pules for the Pronunciation of Pharmaceutical Terins, 
A Prosodiacal Vocabulary of the Karnes of Drugs, etc., and a series of 
Abbreviated Prescriptions illustrating the use of the preceding terms, etc.; 
to which is added a Key, containing the Prescriptions in an unabbreviated 
Form, with a Literal Translation, intended for the use of Medical and 
Pharmaceutical Students. By Jonathan Pekeira, M.D., F.R.S., etc. 
From the Fourteenth London Edition. 

Price, in cloth, » $1.25 

" in leather, with Tucks and Pocket, . . . 1.50 

This little work lias passed through fourteen editions in London and several in this 
country. The present edition of which this is a reprint has been carefully revised 
and many additions made to it. Its great value is proven both by its large sale and 
the many favorable notices of it in the Medical Press. 

Physicians Yisiting List. Published annually. 

SIZES AND PRICE. 

For 25 Patients weekly. Tucks, pockets, and pencil, $1 25 

53 » " " » " 1 53 

75 " " " " « 1 75 

133 " " " » » 2 25 

60 « "H-ta-fJ^S'ST-} " SSO 

100 « "2vol S .{j^ y t°^ e -} « 3 00 

Also, AN INTERLEAVED EDITION, 

for the use of Country Physicians and others who compound their own Prescriptions. 
or furnish Medicines to their patients. The additional pages can also be used for Special 
Memoranda, recording important cases. &c, &c. 

For 25 Patients weekly, interleaved, tucks, pockets, etc., . . . . . $1 50 

50 " " " " 2 00 

50 u u 2vols . |J«.tataaJ M u 300 

Prince's Orthopedic Surgery. 

Orthopedics: A Systematic Work upon the Prevention and Cure of 
Deformities. By David P?.i>:ce, M.D. With Numerous Illustrations. 
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of compilation can be so. Such a book was wanted, and it deserves success." — Med. &■ Surg. Reporter. 

Prince's Plastic Surgery. 

A New Classification and a Brief Exposition of Plastic Surgery. By 
David Prince, M. D. In One Volume Octaco. With Numerous Illus- 
trations. Price, $1.50 



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Radcliffe's Lectures on Epilepsy, Pain, Pa- 
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room to theorize, which his subject afforded, he has not failed to bring forward strong and' formidable facts to 
prove ihe deductions he attempts to draw. We recommend it to the notice of our readers as a work that will 
throw much light upon the Physiology and Pathology of the Nervous System." — Canada Medical Journal,. 

Robertson's Manual on Extracting Teeth. 

Founded on the Anatomy of the Parts involved in the Operation; the Kinds 
and Proper Construction of the Instruments to be vised; the Accidents 
liable to occur from the Operation, and the Proper Remedies to retrieve 
such Accidents. By Abraham Robertson, D.D.S., M.D., Author of 
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tions. Second Edition. Revised and Improved. . . $1.50 

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the operation of extracting teeth." — Dental Cosmos. 

Banking's Half-yearly Abstract of the Medi- 
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Renouard's History of Medicine. 

History of Medicine from its origin to the Nineteenth Century. With an 
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from the French by Cornelius G. Comegys, M. D., Professor of the 
Institutes of Medicine in the Medical College of Ohio, etc. In One 
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renovation."— American Journal of Medical Science. 

"The best history of medicine extant, and one that will find a place in the library of every physician who 
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Reese's Analysis of Physiology. 

Being a Condensed View of the most important Facts and Doctrines, de- 
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Reese's American Medical Formulary. 

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Sydenham Society's Publications. New series,™* 

to 1869 inclusive, 11 years, 44 vols. Subscriptions received, and back 
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Sansoin on Chloroform. 

Its Action and Administration, by Arthur Ernest Sansom, M.B., 
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•'The work of Dr. Sansom may be characterized as most excellent. Written not alone from a theoretical 
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although iu his preface he objects to the 'hackneyed expression of endeavoring to supply a want,' this is just 
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' <:al Journal. 



Scanzoni's Practical Treatise on the Diseases 

of the Sexual Organs of Women. 

Translated from the French of Drs. H. Dor and A. Socin, and annotated 
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Stokes on the Diseases of the Heart and the 

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Spratt's Obstetrical Tables. 

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Skoda on Auscultation and Percussion. 

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Price, bound in cloth, $6.00 

" in leather, 7.00 

Dr. Tanner's work on the Practice of Medicine is so well known in this country, and 
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that was useful and practical in the smaller volume has been retained and much new 
matter added, written in the same condensed and easy style. 

"The leading feature of this book is its essentially practical character. Dr. Tanner has produced a more 
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Tanner's Practical Treatise on the Diseases 
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Octavo $3.00 

This book differs from other works of the kind, in embracing a wider range of sub- 
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fact, of everything which is not of practical importance in the study and treatment of 
children's diseases, is omitted. 

Tanner's Index of Diseases and their Treat- 
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With upwards of 500 Formulas for Medicines, Baths, Mineral Waters, 
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collection of Formula}, and an account of the climates of the various parts of the world suitable for invalids. It 
also contains at the beginning of the work a tabular synopsis of subjects, which does double duty at once, a 
Nosology and an index. It will bo found a most valuable companion to the judicious practitioner." — Lancet. 

Tanner's Memoranda of Poisons. 

From the Second London Fdition. . .... $0.60 



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Trousseau's Lectures on Clinical Medicine. 

Delivered at the Hotel Dieu, Paris, by A. Trousseau, Professor of Clini- 
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with Notes and Appendices, by P. Victore Bazike, M.D., Assisted 
Physician to the National Hospital for the Paralyzed and Epileptic, &c. 

Volume One. Cloth, 6.00 

Volume Two, now Ready, 6.00 

a This book furnishes us with an example of the best kind of clinical teaching, and we are much indebted 
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void of that prolixity which, desirable as it is for purposes of extended analysis, is highly undesirable when 
the object is to point to a practical lesson." — London Medical Times and Gaze/t*. 

Tyler Smith's Obstetrics. 

A Course of Lectures. By William Tyler Smith, M.D., Physician, Ac- 
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Toynbee on Diseases of the Ear. Their Nature, 

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Thompson's Clinical Lectures on Pulmonary 
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Tyson's Cell Doctrine: 

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Tilt's Elements of Health, and Principles of 
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By F. J. Tilt, M.D., Senior Physician to the Lying-in Charity, Author 
of Works on the Diseases of Menstruation, Uterine Therapeutics, &&, 
&c. 12mo 81 50 

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Taylor's Theory and Practice of the Move- 
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Or, the Treatment of Lateral Curvature of the Spine, Paralysis, Indigestion^ 
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other Chronic Affections, by the Swedish System of Localized Movements. 
By Chart.es Taylor, M.D. With Illustrations. 12mo. . 81.50 

The work of Dr. Taylor is a systematic treatise, containing the principles on which, 
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most satisfactory manner. The work is purely of a scientific character, and commends 
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Virchow's Cellular Pathology. 

As based upon Physiological and Pathological History. Translated from 
the Second Edition of the Original. By Frank Chance, B.A., M.A., 
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Virchow on Morbid Tumors. 

IN PREPARATION. 

Walker on Intermarriage. 

Or, the Mode in which, and the Causes why, Beauty, Health, and Intellect 
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others. With Illustrations. By Alexander Walker, Author of 
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Medical Examiner 



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Wythes' Physician's Pocket, Dose, and Symp- 
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Containing the Doses and Uses of all the Principal Articles of the Materia 
Medica, and Original Preparations; A Table of Weights and Mea- 
sures, Rules to Proportion the Doses of Medicines, Common Abbre- 
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Classification of the Materia Medica, Dietetic Preparations, Table of 
Symptomatology, Outlines of General Pathology and Therapeutics, &c. 
By Joseph H. Wythes, A.M., M.D., &c. The Eighth Revised Edition. 

Price, in cloth, $1.00 

" leather, tucks, with pockets, .... 1.25 

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Waring's Manual of Practical Therapeutics. 

Considered chiefly with reference to Articles of the Materia Medica. By 
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" in leather, 7.00 

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preparations noticed in the work. 

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Weber's Clinical Hand-Book of Auscultation 

and Percussion. 

An Exposition from First Principles of the Method of Investigating 
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Walton's Operative Ophthalmic Surgery. 

By Haynes Walton, F.R.C.S., Surgeon to the Central London Ophthal 
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Watson's Practice abridged. 

A Synopsis of the Lectures on the Principles and Practice of Physic. De- 
livered at King's College, London, by Thomas Watson, M.D., Fellow 
of the Royal College of Physicians, &c, &c. From the last London 
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Wells' Treatise on the Diseases of the Eye, 

illustrated by Ophthalmoscopic Plates and Numerous Engravings on 
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Wright on Headaches. 

Their Causes and their Cure. By Henry G. Wright, M.D., Member 
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at the cost of a single visit, he should not let his patient suffer for .want of it." — 
Medical and Surgical Reporter. 

Wells on Long, Short, and Weak Sight, and 

their Treatment by the Scientific Use of Spectacles. Third Edition Re- 
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Wells. Octavo. ..... Price, $3.00 



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Harris's Dictionary of Medical Terminology, 

Dextal Surgery, and the Collateral Sciences. By Chapin A. 
Harris, M.D., D.D.S., Professor of the Principles of Dental Surgery in 
the Baltimore College, Member of the American Medical Association, &c, 
&c. The Third Edition, carefully revised and enlarged, by Ferdi- 
nand J. S. Gorgas, M.D., D.D.S., Professor of Denial Surgery in the 
Baltimore College, &c, &c. Royal octavo. Cloth, $6.50. Leather, $7.50 

This Dictionary has been for a long time out of print; a new edition has been much 
needed by the Profession, a constant and increasing demand existing for it. The pres- 
ent edition has been thoroughly revised by Professor Gorgas, Dr. Harris's successor iD 
the Baltimore Dental College. Many additions and corrections have been made, and 
some cto to three thousand new words added. The doses of the more prominent medici- 
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Harris's Principles and Practice of Dental 
Surgery. 

The Ninth Edition, with 320 Illustrations, Royal octavo. 
Price, bound in cloth, bevelled boards, .... $6.00 
leather, 7.00 

This edition of Dr. Harris's work has been subjected to a very thorough revision 
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Bond's Practical Treatise on Dental Medicine. 

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The Third Edition. Octavo 83.00 

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Robertson's Manual on Extracting Teeth. 

Founded on the Anatomy of the Parts involved in the Operation, the Kinds 
and Proper Construction of the Instruments to be Used, the Accidents 
likely to occur from the Operation, and the Proper Remedies to be I 
By A. Robertson, M.D., D.D.S., &c. A New Revised Edition. $1.50 

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jurgeou." — Dental Cosmos. 



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Taft's Practical Treatise on Operative Den- 
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A NEW EDITION, THOROUGHLY REVISED. 

By Jonathan Taft, D.D.S., Professor of Operative Dentistry in the Ohio 
College of Dental Surgery, &e. The Second Edition, thoroughly Revised, 
with additio7is, and fully brought up to the present state of the Science. 
Containing over 100 Illustrations. Octavo. Leather, . . $4.50 

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very clear, showing that the author is practically familiar with the art which he teaches. The engravings 
are abundant and excellent, and, in fact, the whole mechanical execution of the volume is admirable, and 
reflects much credit on the publishers." — Boston Medical and Surgical Journal. 

Fox on the Human Teeth. 

Their Natural History and Structure, the Treatment of the Diseases to 
which they are Subject, the Mode of Inserting Artificial Teeth, &c. Edited 
by Chapin A. Harris, M.D., D.D.S., &c. With 250 Illustrations. 
Octavo $4.00 

Richardson's Practical Treatise on Mechani- 
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SECOND EDITION, MUCH ENLARGED. 

By Joseph Kichardson, D.D.S., Professor of Mechanical Dentistry in 
the Ohio College of Dental Surgery, &c. With over 150 beautifully exe- 
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Sandy's Text-Book of Anatomy, 

And Guide to Dissections. For the Use of Students of Medicine and 
Dental Surgery. By Washington R. Handy, M.D.,7ate Professor of 
Anatomy and Physiology in the Baltimore College of Dental Surgery. 
With 312 Illustrations. Octavo.. . . . . . $4.00 

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Piggot's Dental Chemistry and Metallurgy. 

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Snowden Piggot, M.D., Professor of Practical and Analytical Chem- 
istry, &c. In one Volume, octavo. $3.50 

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Tomes' System of Dental Surgery. 

By John Tomes, F.R.S., Dentist to the Dental Hospital of London, Author 
of " Tomes 1 Dental Physiology," &c, &c. With 208 beautifully executed 
Illustrations. Octavo. $4.50 

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Oooley's Toilet and Cosmetic Arts. 

The Toilet and Cosmetic Arts, in Ancient and Modern Times. With a 
Review of the Different Theories of Beauty and copious allied Informa- 
tion, Social, Hygienic, and Medical, including Instructions and Cautions 
respecting the Selection and Use of Perfumes, Cosmetics, and other Toilet 
icles ; and a Comprehensive Collection of Formulas, and Directions 
for their Preparation. By Arnold J. Cooley, Author of " Cyclopaedia 
of Receipts : Processes, Data, and Collateral Information, &c.,in the Arts 
and Manufactures" With Index to about 5000 Matters of Interest, Use 
or Caution. Demi-Octavo. ....... $3.00 

Ott on the Manufacture of Soaps and Candles. 

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40. A Catalogue of the Portraits issued in the Society's Atlas of Skin Diseases. (Part I.) 

Series for 1869. (Eleventh- Year.) 

42. Trousseau's Clinical Medicine. Translated and edited by Dr. Rose Cormack. Vol.11. 

43. Biennial Retrospect of Medicine and Surgery, for 1867-8. Edited by Di. Anstie, Dr. Barnes, Mr. Holmes, 

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44. A Ninth FASCiccLus'of the Atlas of Portraits of Skin Diseases. 

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THE SURGERY AID DISEASES OF THE EYE. 

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ophthalmic diseases as this. Without depreciating the large and valuable treatises on 
this subject that have recently appeared, we have long felt that a manual was wanted 
which would serve as a text-booh for students, and also should form a trustworthy guide 
for practitioners in dealing with diseases of the eye. Well has Mr. Lawson supplied 
this want. He has described the various affections of the eye, briefly but yet clearly, 
and from the large experience he has acquired as surgeon to the Royal London Oph- 
thalmic Hospital, Moorfields, he has made his work thoroughly practical. The profession 
will find this manual just the sort of work they want on eye diseases, while to the 
student it will be invaluable as a text-book." — British Medical Journal, July 24, 1869. 

Wells on Long, Short, and Weak Sight, 

And their Treatment by the Scientific Use of Spectacles. The Third 
Edition, Revised, with Additions and Numerous Wood-Cuts and other 
Illustrations. By J. Scelberg Wells. In One Yolume Octavo, 
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Dixon's Guide to the Practical Study of 

Diseases Of the Eye, with an Outline of their Medical 

and Operative Treatment, with Test Types and Illustrations. A New 
and thoroughly Revised Edition, and a great portion Rewritten. By 
James Dixon, F. R. C. S., Surgeon to the Royal London Ophthalmic 
Hospital, &c, &c. In One Yolume. Price, . . . $2.50 



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Dr. Aitken's work is now the most comprehensive Text-Book on the Practice of Medicine in the English 
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Cazeaux's Great Work on Obstetrics. 

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A Theoretical and Practical Treatise on Midwifery. Including the Dis- 
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the Faculty of Medicine of Paris, &c, &c. Revised and Annotated 
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Hewitt's Diagnosis, Pathology, and Treat- 
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versity College, and Obstetric Physician in University College Hospital. 
Second Edition, Revised and Enlarged, with an entirely New Series of 
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Byford's Practice of Medicine and Surgery, 

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and Children in the Chicago Medical College, &c, &c. The Second 
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Bound in Cloth, Price, $5.00 

Leather 6.00 



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